Women's empowerment, intrahousehold influences, and health system design on modern contraceptive use in rural Mali: a multilevel analysis of cross-sectional survey data

BACKGROUND

Persistent challenges in meeting reproductive health and family planning goals underscore the value in determining what factors can be leveraged to facilitate modern contraceptive use, especially in poor access settings. In Mali, where only 15% of reproductive-aged women use modern contraception, understanding how women's realities and health system design influence contraceptive use helps to inform strategies to achieve the nation's target of 30% by 2023.

METHODS

Using household survey data from the baseline round of a cluster-randomized trial, including precise geolocation data from all households and public sector primary health facilities, we used a multilevel model to assess influences at the individual, household, community, and health system levels on women's modern contraceptive use. In a three-level, mixed-effects logistic regression, we included measures of women's decision-making and mobility, as well as socio-economic sources of empowerment (education, paid labor), intrahousehold influences in the form of a co-residing user, and structural factors related to the health system, including distance to facility.

RESULTS

Less than 5% of the 14,032 women of reproductive age in our study used a modern method of contraception at the time of the survey. Women who played any role in decision-making, who had any formal education and participated in any paid labor, were more likely to use modern contraception. Women had three times the odds of using modern contraception if they lived in a household with another woman, typically a co-wife, who also used a modern method. Compared to women closest to a primary health center, those who lived between 2 and 5 km were half as likely to use modern contraception, and those between 5 and 10 were a third as likely.

CONCLUSIONS

Despite chronically poor service availability across our entire study area, some women-even pairings of women in single households-transcended barriers to use modern contraception. When planning and implementing strategies to expand access to contraception, policymakers and practitioners should consider women's empowerment, social networks, and health system design. Accessible and effective health systems should reconsider the conventional approach to community-based service delivery, including distance as a barrier only beyond 5 km.

Zika virus public health crisis and the perpetuation of gender inequality in Brazil

BACKGROUND

In 2015-2017, the Americas experienced a highly consequential epidemics for pregnancy and childbearing. Mainly transmitted by the mosquito Aedes aegypti, but also through sexual intercourse, the Zika virus poses the risk of congenital Zika syndrome to fetus, which includes microcephaly and other child development complications. When a public health crisis taps directly into reproductive health, typically a feminine realm, responses to the emergency may exacerbate deeply-rooted gender norms. This paper investigates the role of gender in two relational contexts: (a) the government-led response to the pandemic in terms of communication campaigns aimed at preventing Zika infections; and (b) an individual level of response to the emergency, concerning women's negotiation with their sexual partners with regard to the prevention of Zika as well as pregnancies.

METHODS

We conducted content analysis of 94 unique pieces from public health communication campaigns produced by governmental agencies with the goal of promoting Zika awareness. Print and online materials were collected from May 2016 to August 2017, and included TV ads, Internet Pop-ups, and pamphlets. We also analyzed transcripts from 16 focus groups conducted with reproductive-aged women (18-40) in Belo Horizonte and Recife, two large cities differently affected by the Zika outbreak. Women answered open-ended questions connected to the epidemic, in areas such as personal knowledge and experiences with the Zika virus, experiences of their friends and acquaintances, their primary information sources, their perceptions of public health efforts toward containing the outbreak, as well as women's contraceptive use.

RESULTS

Campaign pieces handling pregnancy and microcephaly were largely gendered. Pieces targeted women, placing on their shoulders the responsibility for protecting a potential fetus from the disease. Importantly, campaigns neglected addressing male's participation on Zika prevention and contraceptive management, while failing to take into account Brazil's large proportion of unplanned pregnancies. Women were placed in a double bind by being expected to prevent both pregnancy and Zika, in a context where gendered power imbalances often translate in women having little power/means for condom negotiation/avoiding unprotected sexual intercourse.

CONCLUSION

Government and individual responses to the epidemics reinforced gender roles, situating pregnant women as responsible for averting mosquito bites and microcephaly. Further, prevention campaigns largely excluded men. Since low-socioeconomic status women possessed fewer resources to preclude infection, we also found that beyond the gender divide, this subgroup faced more pronounced Zika prevention challenges as they found it harder to negotiate condom use with their sexual partners and often could not access other types of contraceptives resulting in unplanned pregnancies.

Modern contraceptive use among unmarried girls aged 15-19 years in South Western Nigeria: results from a cross-sectional baseline survey for the Adolescent 360 (A360) impact evaluation

PURPOSE

Adolescents 360 (A360) is an initiative being rolled out across Nigeria with the aim of increasing voluntary modern contraception use among women aged 15 to 19 years. Using evaluation study baseline data, we identified sexuality, fertility and contraceptive use characteristics of young unmarried girls in South Western Nigeria.

METHODS

A cross-sectional baseline survey of unmarried girls aged 15 to 19 years was conducted in Ogun state, Nigeria in August 2017. A clustered sampling design was used. We identified determinants of modern contraceptive use in this subpopulation using logistic regression.

RESULTS

Of 12,024 women interviewed, 15.3% reported sexual intercourse in the past year. The majority of respondents (79.6%, 9525/11,967) had heard of contraception. 45.3% of sexually active respondents were using a modern contraceptive method. Of those using any method of contraception, male condoms (50.3%) were the most widely used modern method followed by the emergency contraceptive pill (16.7%). Following adjustment for socio-demographic characteristics, there was evidence that the use of modern contraception was positively associated with having never given birth, living in an urban area, current enrolment in education, high level of education, high socioeconomic status, exposure to information about contraception, perceived social support for contraception, and self-efficacy for contraception.

CONCLUSIONS

In South Western Nigeria, unmarried sexually active adolescent girls have relatively low levels of modern contraceptive use. Programmes should aim to increase access to modern contraception and to increase social support and acceptability of contraceptive use.

Socio-economic and demographic factors associated with fertility preferences among women of reproductive age in Ghana: evidence from the 2014 Demographic and Health Survey

BACKGROUND

Understanding women's desire to have more children is critical for planning towards future reproductive health behaviour. We examined the association between socio-economic and demographic factors and fertility preferences among women of reproductive age in Ghana.

METHODS

This  study used data from the 2014 Ghana Demographic and Health Survey. The sample consisted of 5389 women of reproductive age. We fitted Binary logistic regression models to assess the association between socio-economic status and fertility preferences, whiles controlling for demographic factors. The results were presented as crude odds ratios (cORs) and adjusted odds ratios (aORs) together with their corresponding 95% confidence intervals.

RESULTS

Approximately 60% of women of reproductive age in Ghana desired for more children. Women with no formal education were more likely to desire for more children compared to those with higher level of education (aOR = 2.16, 95% CI 1.29-3.48). The odds of desire for more children was higher among women who lived in rural areas compared to those who lived in urban areas (aOR = 1.24, 95% CI 1.01-1.53). With region, women who lived in the Northern region were more likely to desire for more children compared to those who lived in the Ashanti region (aOR = 4.03, 95% CI 2.69-6.04). Similarly, women who belonged to other ethnic groups were more likely to desire for more children compared to Akans (aOR = 1.78, 95% CI 1.35-2.35). The desire for more children was higher among women with 0-3 births compared to those with four or more births (aOR = 7.15, 95% CI 5.97-8.58). In terms of religion, Muslim women were more likely to desire for more children compared to Christians (aOR = 1.87, 95% CI 1.49-2.34).

CONCLUSION

This study concludes that women in high-socio economic status are less likely to desire more children. On the other hand, women in the Northern, Upper East and those belonging to the Islamic religious sect tend to desire more children. To aid in fertility control programmes designing and strengthening of existing ones, these factors ought to be critically considered.

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.

Why do women discontinue contraception and what are the post-discontinuation outcomes? Evidence from the Arusha Region, Tanzania

In Africa, high discontinuation of contraceptive use is thwarting goals for healthy birth spacing or limiting childbearing. This paper investigates how well the contraception program is addressing the needs of women and couples in the Arusha region, Tanzania by studying contraceptive use continuation. We measured the overall and method-specific discontinuation rate, reasons for discontinuation, post-discontinuation reproductive behaviours/outcomes, and examined the determinants of contraceptive discontinuation. We used data from a household survey conducted in Arusha from January to May 2018. Information on contraceptive use during the 31 months preceding the survey was recorded in a monthly calendar. Using the single- and multiple-decrement life-table approach, we calculated the overall and cause-specific discontinuation of contraceptive methods. Logistic regression was used to evaluate the determinants of discontinuation. The 12-month overall discontinuation of contraceptive use was 44.6%. Discontinuation was lowest for implants (12.3%) and highest for male condoms (60.1%), the most common reason being side effects (11.7%). 59.8% of women who discontinued did not switch to another method within 3 months following discontinuation and 20.9% experienced pregnancy. Longer distance to a health facility is associated with higher discontinuation of hormonal methods such as injectables, but lower discontinuation of non-hormonal methods such as condoms. Discontinuation due to side effects is not explained by most of the women's background characteristics other than the method they used. Discontinuation of contraception is high among Arusha women. Effective contraception programs, especially improved counselling, need to address the reasons for the discontinuation of contraceptive use.

Contraceptive Decision Making Among Latina Immigrants: Developing Theory-Based Survey Items

BACKGROUND

Contraception is important for reproductive autonomy, yet many Latinas do not use contraception consistently despite research reporting a desire to do so. Factors varying in priority and value come into play during contraceptive decision making. When measuring these, relevant survey items may vary by populations.

AIM

This study focused on developing an ethnically responsive, patient-centered, content-valid survey for measuring factors that influence contraceptive decision making among immigrant Latinas.

METHOD

Nonpregnant self-identified Latinas ages 15 to 24 years in Baltimore, MD, were recruited from a family planning facility. Using the theory of planned behavior as a theoretical framework and prior formative research, initial survey items were drafted (Step 1). Content validation and cognitive interviewing procedures (Step 2 and Step 3) were used to develop final items.

RESULTS

Final items (27) were content-validated by the target population; items reflect important factors and relevant contexts affecting contraceptive decision making among Latinas in Baltimore.

DISCUSSION

These theory-based items provide an important contribution to the literature because they measure and explore factors related to contraceptive decision making in an understudied population. Providers might consider these factors during counseling to build patient-centered communication. These items might serve to measure responses to theory of planned behavior-based interventions designed to improve the contraceptive counseling of Latinas.

Implementing social accountability for contraceptive services: lessons from Uganda

BACKGROUND

Growing evidence shows that social accountability contributes to improving health care services, with much promise for addressing women's barriers in contraceptive care. Yet little is known about how social accountability works in the often-complex context of sexual and reproductive health, particularly as sex and reproduction can be sensitive topics in the open and public formats typical of social accountability. This paper explores how social accountability operates in the highly gendered and complex context of contraceptive care.

METHODS

This exploratory research uses a case study approach to provide a more grounded understanding of how social accountability processes operate in the context of contraceptive information and services. We observed two social accountability projects that predominantly focused on contraceptive care in Uganda over a year. Five instruments were used to capture information from different source materials and multiple respondents. In total, one hundred and twenty-eight interviews were conducted and over 1000 pages of project documents were collected. Data were analyzed and compiled into four case studies that provide a thick description of how these two projects operated.

RESULTS

The case studies show the critical role of information, dialogue and negotiation in social accountability in the context of contraceptive care. Improved community and health system relationships, community empowerment, provider and health system responsiveness and enhanced availability and access to services were reported in both projects. There were also changes in how different actors related to themselves and to each other, and contraceptive care, a previously taboo topic, became a legitimate area for public dialogue.

CONCLUSION

The study found that while social accountability in the context of contraceptive services is indeed sensitive, it can be a powerful tool to dissolving resistance to family planning and facilitating a more productive discourse on the topic.

History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans

BACKGROUND

Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services.

OBJECTIVES

The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care.

STUDY DESIGN

Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex.

RESULTS

Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex.

CONCLUSION

Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.

Unmet need for family planning services among young married women (15-24 years) living in urban slums of India

BACKGROUND

NFHS-4 stated high unmet need for family planning (FP) among married women in Uttar Pradesh. Unmet need is highest among age groups: 15-19 and 20-24 years. Currently few data is available about unmet need for FP among vulnerable section of the community, i.e.15-24 year's age group living in the urban slums. Therefore this study was conducted to assess the unmet need for FP services and its determinants among this under-privileged and under-served section of society residing in urban slums of Uttar Pradesh, India.

METHODS

Cross sectional study was conducted in the slums of Lucknow, India. One Urban-Primary Health Centre (U-PHC) was randomly selected from each of the eight Municipal Corporation zones in Lucknow and two notified slums were randomly selected from each U-PHC. All the households in the selected slums were visited for interviewing 33 young married women (YMW) in each slum, with a pre-structured and pre tested questionnaire, to achieve the sample size of 535. Analysis of the data was done using logistic regression.

RESULTS

The unmet need for family planning services among YMW was 55.3%. About 40.9% of the unmet need was for spacing methods and 14.4% for limiting methods. Important reasons cited for unmet need for family planning services were negligent attitude of the women towards family planning, opposition by husband or others, embarrassment / hesitation / shyness for contraceptive use, poor knowledge of the FP method or availability of family planning services. Among method related reasons health concerns and fear of side effects were frequently cited reasons. On multiple logistic regression: age, educational status, duration of marriage, number of pregnancies, knowledge of contraceptive methods, opposition to contraceptive use and contact with Auxiliary Nurse Midwife (ANM) showed independently significant association with unmet need for family planning services.

CONCLUSIONS

Unmet need for family planning services is very high among the YMW of urban slums. The findings stress that program managers should take into cognizance these determinants of high level of unmet need for family planning among YMW and make intense efforts for addressing these issues in a holistic manner.

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.

The socioeconomic and lifestyle determinants of contraceptive use among Chinese college students: a cross-sectional study

BACKGROUND

Chinese youth have become more sexually active over the years, yet their behaviours of contraceptive use are influenced by socioeconomic and lifestyle factors. This study aimed to investigate the socioeconomic and lifestyle determinants of contraceptive use among Chinese college students, and to investigate quantitatively their reasons for choosing different contraceptive methods.

METHODS

The study used the data from a cross-sectional survey, which was conducted in 2015 among 17,517 students from 130 colleges and professional schools in mainland China. Chi-square tests were performed to test the differences in the awareness and uses of contraceptives between male and female students. Multivariable logistic regression models were used to analyse the associations between socioeconomic and lifestyle factors and contraceptive uses.

RESULTS

Condoms (95%), oral contraceptives (91%) and emergency contraceptives (71%) were the most commonly known contraceptive methods among the sample of Chinese youth that were surveyed. Among male participants, high monthly expenditure (OR = 1.37, 95%CI: 1.07-1.75), light alcohol consumption (OR = 1.47, 95%CI: 1.03-2.11), and high sexual knowledge (OR = 1.96, 95%CI: 1.57-2.45) were positively associated with contraceptive uses, while tobacco use (OR = 0.47, 95%CI: 0.23-0.95) showed a negative association with contraceptive uses. Among female students, suburban residency (OR = 1.38, 95%CI: 1.03-1.83), high level of parental education (OR = 1.96, 95%CI: 1.19-3.22), moderate alcohol consumption (OR = 2.66, 95%CI: 1.05-6.77), and high sexual knowledge (OR = 1.50, 95%CI: 1.18-1.91) were positively associated with contraceptive uses, while tobacco use (OR = 0.60, 95%CI: 0.36-0.99) showed a negative association.

CONCLUSIONS

A series of socioeconomic and lifestyle factors were associated with contraceptive choices among Chinese college students. Targeted sexual education programs are in demand to improve the awareness and the use of contraceptives in this population.

Positive Deviance for Dual-Method Promotion among Women in Uganda: A Qualitative Study

Dual-method use is the most reliable form of protection against unintended pregnancies and human immunodeficiency virus/sexually transmitted infections (HIV/STIs). Although dual-method use remains uncommon among women in stable relationships, some women do practice it. In this study, we explored the barriers that make dual-method use rare and the behaviors of women who practice dual-method use using a positive deviance framework in Uganda. We screened 150 women using highly effective contraceptives at five health facilities. We identified nine women who practiced dual-method use and 141 women who did not. In a qualitative study, we conducted in-depth interviews with all nine women practicing dual-method use and 10 women randomly selected out of the 141 who did not. We performed a thematic analysis using the positive deviance framework. Regardless of practicing dual-method use or not, women faced perceived barriers against dual-method use, such as partner’s objection, distrust, shyness about introducing condoms into marital relationships, and limited access to condoms. However, women practicing dual-method use had higher levels of risk perception about unintended pregnancies and HIV/STIs. They also engaged in unique behaviors, such as influencing their partners’ condom use by initiating discussions, educating their partners on sexual risks and condom use, and obtaining condoms by themselves. These findings will be useful in developing effective community-led and peer-based interventions promoting dual-method use to reduce the dual burden of unintended pregnancies and HIV/STIs among women in Uganda.

Induced abortion: a cross-sectional study on knowledge of and attitudes toward the new abortion law in Maputo and Quelimane cities, Mozambique

BACKGROUND

Maternal mortality, of which 6.7% is attributable to abortion complications, remains high in Mozambique. The objective of this paper is to assess the level of induced abortion at the community, as well as to assess awareness of and attitudes towards the new abortion law among women of reproductive age in suburban areas of Maputo and Quelimane cities.

METHODS

A cross-sectional household survey among women aged 15-49 years in Maputo and Quelimane cities was conducted using a multi-stage clustered sampling design. Data on sociodemographic characteristics, maternal outcomes, contraceptive use, knowledge and attitudes towards the new abortion law were collected. Bivariate and multiple logistic regression analysis using the complex samples procedure in SPSS were applied.

RESULTS

A total of 1657 women (827 Maputo and 830 Quelimane) were interviewed between August 2016 and February 2017. The mean age was 27 years; 45.7% were married and 75.5% had ever been pregnant. 9.2% of the women reported having had an induced abortion, of which 20.0% (17) had unsafe abortion. Of the respondents, 28.8% knew the new legal status of abortion. 17% thought that the legalization of abortion was beneficial to women's health. Having ever been pregnant, being unmarried, student, Muslim, as well as residing in Maputo were associated with higher odds of having knowledge of the new abortion law.

CONCLUSION

Reports of abortion appear to be low compared to other studies from Sub-Saharan African countries. Furthermore, respondents demonstrated limited knowledge of the abortion law. Social factors such as education status, religion, residence in a large city as well as pregnancy history were associated with having knowledge of the abortion law. Only a small percentage of women perceived abortion as beneficial to women's health. There is a need for widespread sensitization about the new law and its benefits.

Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries

BACKGROUND

There is ample evidence that gender norms affect contraceptive practice; however, data are mostly qualitative with limited geographical scope. We investigated that association quantitatively using collective community-level attitudes towards premarital sex and wife-beating as proxies for gender norms.

METHODS

Data came from nationally representative Demographic and Health Surveys (2005-2009) for women of reproductive age (15-49 years) in nine sub-Saharan African countries. Using multilevel logistic models, controlling for individual covariates and community-level indicators of women's empowerment, we assessed the community-level association of gender norms regarding premarital sex and wife-beating with individual contraception uptake and demand satisfied among fecund sexually active women. Norms were approximated as 'collective attitudinal norms' from female/male residents (aged 15-49 years) from the same community. We assessed the magnitude and significance of the community-level effects and attributed variance across communities. The same analysis was replicated for each country.

RESULTS

In a fully-adjusted model with a pooled sample of 24 404 adolescent women, the odds of contraception use increased with a 1 standard deviation (SD) increase in the variation of collective permissive attitudes towards premarital sex of female (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.02-1.15) and male (OR = 1.11, 95% CI = 1.05-1.17) peers (15-24 years), while odds of contraceptive use declined by 10% (OR = 0.90, 95% CI = 0.85-0.96) with collective accepting attitudes towards wife-beating of women aged 15-49 years. Similar results were found in separate models that controlled for adults' permissive attitudes towards premarital sex. The community-level attributed variance (V2 = 1.62, 95% CI = 1.45-1.80) represented 33% (intra-class correlation (ICC) = 33.0, 95% CI = 30.0-35.4) of the total variation of contraception use, and attitudes towards premarital sex and violence jointly explained nearly 26% of that V2 variance. The community-level shared of attributed variation of contraceptive use varied significantly across countries, from 3.5% in Swaziland (ICC = 3.5, 95% CI = 0.8-13.7) to 60.2% in Nigeria (OR = 60.2, 95% CI = 56.0-64.2).

CONCLUSIONS

Overall, significant positive associations of collective permissive attitudes of both adolescent and adult women towards premarital sex were found for use of, and demand for, contraception, whereas collective accepting attitudes towards wife-beating were negatively associated with the use and demand for contraception. Ours is the first study to define quantitatively the influence of proxies for gender norms at the community level on women's family planning decisions. These findings offer new insights for understanding the role of sex-related attitudes and norms as important factors in shaping contraceptive practices and improving the effectiveness of family planning policies by targeting individuals as well as their groups of influence.

Side effect concerns and their impact on women's uptake of modern family planning methods in rural Ghana: a mixed methods study

BACKGROUND

Despite availability of modern contraceptive methods and documented unmet need for family planning in Ghana, many women still report forgoing modern contraceptive use due to anticipated side effects. The goal of this study was to examine the use of modern family planning, in particular hormonal methods, in one district in rural Ghana, and to understand the role that side effects play in women's decisions to start or continue use.

METHODS

This exploratory mixed-methods study included 281 surveys and 33 in-depth interviews of women 18-49 years old in the Amansie West District of Ghana between May and July 2018. The survey assessed contraceptive use and potential predictors of use. In-depth interviews examined the context around uptake and continuation of contraceptive use, with a particular focus on the role of perceived and experienced side effects.

RESULTS

The prevalence of unmet need for modern family planning among sexually active women who wanted to avoid pregnancy (n = 135) was 68.9%. No factors were found to be significantly different in comparing those with a met need and unmet for modern family planning. Qualitative interviews revealed significant concerns about side effects stemming from previous method experiences and/or rumors regarding short-term impacts and perceived long-term consequences of family planning use. Side effects mentioned include menstrual changes (heavier bleeding, amenorrhea or oligomenorrhea), infertility and childbirth complications.

CONCLUSION

As programs have improved women's ability to access modern family planning, it is paramount to address patient-level barriers to uptake, in particular information about side effects and misconceptions about long-term use. Unintended pregnancies can be reduced through comprehensive counseling about contraceptive options including accurate information about side effects, and the development of new contraceptive technologies that meet women's needs in low-income countries.

Barriers and facilitators to contraceptive use among Somali immigrant women in Oslo: A qualitative study

Background

The European Action Plan for Sexual and Reproductive Health emphasizes the importance of improving access to contraceptive services for disadvantaged groups. However, a prior study showed that the prevalence of abortion is two times higher among refugees compared to non-immigrants in Norway. Similarly, a recent study reported that 50% of Somali women in Oslo had unintended childbirth on one occasion or more. These findings are supported by several studies in Europe that showed immigrant and refugee women have higher rates of unintended pregnancy and abortion than Non-immigrant women, and more than half of immigrants, who seek abortion are not using any form of contraception, raising concerns about their access to utilization of modern contraception. However, none of these studies have explored reasons underlying immigrant women’s underutilization of modern contraception. The present study aimed to explore the barriers and facilitators to contraceptive usage among Somali immigrant women in Oslo area.

Methods

A qualitative study using unstructured in-depth interviews with twenty one Somali women of reproductive age, >18 years, was conducted in Oslo from May—August 2018. The participants were recruited using purposive sampling method. Interviews began with a general question and were followed with some probing questions, and were continued until data saturation was reached. Data were analyzed using thematic analysis.

Results

Although the majority of the participants were educated, aware of the importance of contraceptive methods and interested in child spacing, systemic and socio-cultural barriers were found to be hindering their access to contraception. Several barriers were identified, including: language problems, lack of adequate information, religious beliefs, gender roles and social pressure.

Conclusion

Eliminating the barriers which prevent women from receiving their desired form of contraception will have important public health implications, including lengthening inter-pregnancy intervals, and fewer unplanned pregnancies and abortions. These findings can support policy makers, civil society organizations and health providers to develop cultural sensitive programmes and educational interventions, which help Somali immigrant women overcome the identified barriers to contraception.

A Bidimensional Examination of Machismo in Relation to Risky Sexual Cognitions and Behavior among Latino College Men

Objective: College students and Latina/o individuals are disproportionately affected by adverse consequences related to risky sex, highlighting the importance of examining sociocultural factors related to risky sexual variables among Latina/o college students. We explored the link between machismo (a bidimensional form of masculinity often ascribed to Latino men) and risky sexual outcomes among Latino college men. Methods: Latino college men responded to an online study assessing two dimensions of machismo, and risky sexual cognitions (eg, risky sexual intentions) and behavior (eg, condom use). Results: Among our findings, a hypermasculine dimension of machismo predicted greater intentions to engage in risky sex, and more positive condom use attitudes. A dimension of machismo characterized by respect and chivalry predicted more frequent condom use. Conclusions: These findings indicate the relation between machismo and risky sex among Latino college men is complex, underscoring the need for sociocultural considerations in culturally tailored collegiate sexual-risk prevention programs.

Highly-Effective Contraception Use More Likely Among Native Hawaiian Women than Non-Native Hawaiian Women at Title X Clinics in Hawai'i

Differences in contraceptive method use have been noted among women of different races, but studies describing contraceptive method use among Native Hawaiian women have not been published. To examine method choice in this group, the authors conducted a database review of the Hawai'i State Department of Health Title X program. Reviewed were client visit records (CVRs) that health care providers completed for women who were ages 15-44 years, avoiding pregnancy, not currently pregnant, and using a contraceptive method (N=54 513). Because a patient could have had several visits during the study period, the contraceptive method chosen at the last visit was selected for analysis. Statistical analyses included descriptive statistics, bivariate analyses, and logistic regression. The proportion of Native Hawaiian women who selected a highly-effective method of contraception (HEC), defined as an intrauterine device, implant, or permanent contraception, was higher than the proportion of non-Native Hawaiian women who selected an HEC. Overall, 15.4% of Native Hawaiian women during the study period chose HEC, compared to 8.8% of non-Native Hawaiian women. In a logistic regression analysis, Native Hawaiian women ages 15-29 were 1.46 times more likely to use HEC (95% CI: 1.35-1.58) than non-Native Hawaiian women ages 15-29, and Native Hawaiian women ages 30-44 were 1.69 times more likely to use HEC (95% CI: 1.53-1.87) than non-Native Hawaiian women in the same age group. Because Native Hawaiian women are reported to have higher rates of unintended pregnancy in the state compared to other racial groups, additional research exploring contraceptive non-use and pregnancy intention are needed.

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.

Confronting racism in family planning: a critical ethnography of Roma health mediation

Roma health mediators are part of a government funded, community-led health intervention. One of the programme's central aims is to improve access to reproductive care for Roma women, often said to be one of the most disadvantaged population groups in Europe. This paper is a critical analysis of mediation in Romania, focusing on how social determinants shape access to family planning and how mediators are employed to address inequalities. It is based on ethnographic observations of mediators at work, as well as in-depth interviews with community members, health professionals, and mediators. Health professionals tended to see Roma families as wanting and having an unreasonably large number of children and tried to curtail this through the promotion of contraception. This contrasted with the perspective of community members, who appeared not to choose having many children but who instead struggled to access contraception for financial reasons. Roma health mediators generally seemed aware of multiple and intersecting pressures that women were facing, but ultimately tended to frame family planning as a matter of choice, culture, and knowledge. I set these perspectives against the background of anti-Roma racism and eugenic sentiments, reflected in popular discourses about Roma reproduction. I explore how an intervention that nominally aims to promote the emancipation of Roma communities, in fact entrenches some of the racially fused assumptions that are connected to inequalities of access to reproductive health care in the first place. The discussion has implications for Roma reproductive health interventions across Europe, and for participatory interventions more globally.

Social Ecological Factors of Sexual Subjectivity and Contraceptive Use and Access Among Young Women in the Northwest Territories, Canada

Adolescent women in the Northwest Territories (NWT), Canada, experience many sexual health challenges that are linked to a history of colonization and intergenerational effects of trauma. This study was informed by social ecological theory and explored how young women in the NWT develop sexual subjectivity within the context of contraception use and access during this time of decolonization. A total of 41 participants (aged 13 to 17 years) attended the Fostering Open eXpression among Youth (FOXY) body-mapping intervention in six NWT communities and then completed semistructured interviews. Framework analysis identified barriers to the development of sexual subjectivity that included a culture of stigma and shame surrounding sexuality; pervasive alcohol use in communities; predatory behaviors by older men; poor quality sexual health education offered in schools; and issues with accessing health services. In addition, analysis identified the following facilitators: comprehensive sexual health education; widespread access to free condoms; and positive health support networks with female relatives, peers, and some teachers. Our findings suggest the need for multiple intervention strategies within a complex social ecological framework, including arts-based interventions that focus on developing self-esteem and self-efficacy of youth, combined with interpersonal interventions that strengthen communication skills among supportive adults, and community-level campaigns that target stigma reduction and shift cultural norms.

Use of sexual health services among American Indian and Alaska Native Women

Because use of sexual health services among American Indian/Alaska Native women is understudied we: (1) examined disparities in use of sexual health services between American Indian/Alaska Native and non-Hispanic white women and (2) identified factors associated with service use among American Indian/Alaska Native women. We used data from the National Survey of Family Growth regarding the use of sexual health services collected between 2006 and 2010 from women aged 15-44 years who self-identified as American Indian/Alaska Native (n = 819) and white (n = 6,196). Weighted logistic regression models estimated the likelihood of reporting the use of sexual health services by race and factors associated with use in the American Indian/Alaska Native sample. Compared to whites, American Indian/Alaska Native women were less likely to use birth control services and more likely to use services for sexually transmitted diseases and HIV. Among American Indian/Alaska Natives, younger women were more likely to use birth control services, and women who had a higher number of sexual partners were more likely to use services for sexually transmitted diseases and HIV. Our results provide a national baseline against which to assess disparities and changes in the use of sexual health services among American Indian/Alaska Native women over time.

Contraceptive Desert? Black-White Differences in Characteristics of Nearby Pharmacies

OBJECTIVES

Race differences in contraceptive use and in geographic access to pharmacies are well established. We explore race differences in characteristics of nearby pharmacies that are likely to facilitate (or not) contraceptive purchase.

STUDY DESIGN

We conducted analyses with two geocode-linked datasets: (1) the Relationship Dynamics and Social Life (RDSL) project, a study of a random sample of 1003 women ages 18-19 living in a county in Michigan in 2008-09; and (2) the Community Pharmacy Survey, which collected data on 82 pharmacies in the county in which the RDSL study was conducted.

RESULTS

Although young African-American women tend to live closer to pharmacies than their white counterparts (1.2 miles to the nearest pharmacy for African Americans vs. 2.1 miles for whites), those pharmacies tend to be independent pharmacies (59 vs. 16%) that are open fewer hours per week (64.6 vs. 77.8) and have fewer female pharmacists (17 vs. 50%), fewer patient brochures on contraception (2 vs. 5%), more difficult access to condoms (49% vs. 85% on the shelf instead of behind glass, behind the counter, or not available), and fewer self-check-out options (3 vs. 9%). More African-American than white women live near African-American pharmacists (8 vs. 3%). These race differences are regardless of poverty, measured by the receipt of public assistance.

CONCLUSIONS

Relative to white women, African-American women may face a "contraception desert," wherein they live nearer to pharmacies, but those pharmacies have characteristics that may impede the purchase of contraception.

Attitude of married women towards contraceptive use in Ilorin Metropolis, Kwara State, Nigeria

BACKGROUND

Contraceptive use helps in preventing unplanned pregnancy and reducing maternal death among married women.

OBJECTIVE

To investigate the attitude of married women towards contraceptive use in Ilorin metropolis, Kwara State. The study also examined whether the variables of age and educational attainment would influence attitude of married women towards contraceptive use in Ilorin metropolis.

METHODS

Descriptive survey design and analytical methods were adopted for the study. Simple random sampling technique was adopted to draw a total of 200 respondents. A questionnaire was used to collect data for the study. Mean and rank order was used to answer the research question while Analysis of Variance was used to test the hypotheses at 0.05 alpha level.

RESULTS

The attitude of married women towards contraceptive use in Ilorin metropolis was negative. There was no significant difference in the attitude of married women towards contraceptive use based on age and educational attainment.

CONCLUSION

Most married women in Ilorin metropolis have negative attitude towards contraceptive use. We recommended that counselling services be provided to women on how to deal with side effects associated with various modern contraceptive methods.

Factors Influencing Modern Contraceptive Use among Adolescents in Nepal

In Nepal, contraceptive use among married adolescents is low and has remained nearly stagnant since 2006, while little information is available about contraceptive use among unmarried adolescents. Nepal is committed to improve sexual and reproductive health rights among all the adolescents. Promoting modern contraceptive use especially among married adolescents is one of the key approaches in practice, to prevent HIV or sexual transmitted infections, avoid unintended pregnancy and sub-sequent unsafe abortion. In spite of these efforts, modern contraceptive use among married adolescents is not increasing. In this study, we aimed to review the prevalence and trends as well as factors influencing modern contraceptive use among both married and unmarried adolescents in Nepal. A review of existing published and unpublished articles, documents, and reports were conducted. An adapted and modified socio-ecological model was used to explore the factors influencing contraceptive use. Contraceptive use is persistently low among adolescents. Various interrelated factors like socio-cultural norms and traditions, lack of comprehensive knowledge on contraceptive methods among adolescents, inadequate adolescent friendly Services and health workers not having the competencies to work with adolescents, are the major influential factors that limit adolescents to seek and use contraceptive services and information. A multilevel approach is required to address the interrelated factors and to create an enabling environment in which adolescent are fully informed and equipped to make use of contraceptives and related services. For this to happen, Government and NGOs working on sexual and reproductive health rights have to work towards translating the existing policies into practice. Involving adolescents, their families and communities; equipping teachers to provide comprehensive sex education within school and sex education programme for out of school and enhancing the competencies of health workers to provide adolescent friendly services - all in line with the written policy - is urgently needed. Keywords: Adolescent; barriers; contraceptive; Nepal; SRHR.

Is LARC for Everyone? A Qualitative Study of Sociocultural Perceptions of Family Planning and Contraception Among Refugees in Ethiopia

Objective Ethiopia is home to an increasingly large refugee population. Reproductive health care is a critical issue for these groups because refugee women are at high risk for unmet family planning needs. Efforts to expand contraceptive use, particularly long acting reversible contraceptive (LARC) methods are currently underway in several Ethiopian refugee camps. Despite availability of LARC methods, few refugee women opt to use them. The purpose of this study was to explore how culture influences contraceptive attitudes and behaviors, particularly towards LARC methods, among Ethiopia's refugee populations. Methods Focus group discussions and individual interviews were conducted with Eritrean and Somali refugees living in Ethiopia. The qualitative data was analyzed to identify important themes highlighting the relationship between cultural values and contraceptive attitudes and behaviors. Results Childbearing was highly valued among participants in both study groups. Eritreans reported desire to limit family size and attributed this to constraints related to refugee status. Somalis used cultural and religious faith to deal with economic scarcity and were less likely to feel the need to adapt contraceptive behaviors to reduce family size. Participants held overall positive views of the contraceptive implant. Attitudes toward the intrauterine device (IUD) were overwhelmingly negative due to its long-acting nature. Conclusions Culture, religion and refugee status form a complex interplay with family planning attitudes and behaviors among Eritrean and Somali refugees. For these populations, the three-year implant appears to be a more acceptable contraceptive method than the longer-acting IUD because it is in line with their reproductive plans.

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.

Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011-2015

OBJECTIVE

To investigate whether demographic, socioeconomic, and reproductive health characteristics affect long-acting reversible contraceptive (LARC) use differently by race-ethnicity. Results may inform the dialogue on racial pressure and bias in LARC promotion.

STUDY DESIGN

Data derived from the 2011-2013 and 2013-2015 National Surveys of Family Growth (NSFG). Our study sample included 9321 women aged 15-44. Logistic regression analyses predicted current LARC use (yes vs. no). We tested interaction terms between race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic) and covariates (for example, education, parity, poverty level) to explore whether their effects on LARC use vary by race-ethnicity.

RESULTS

In the race-interactions model, data did not show that low income and education predict LARC use more strongly among Black and Hispanic women than among White women. There was just one statistically significant race-interaction: experience of unintended pregnancy (p=.014). Among Whites and Hispanics, women who reported ever experiencing an unintended pregnancy had a higher predicted probability of LARC use than those who did not. On the other hand, among Black women, the experience of unintended pregnancy was not associated with a higher predicted probability of LARC use.

CONCLUSIONS

With the exception of the experience of unintended pregnancy, findings from this large, nationally representative sample of women suggest similar patterns in LARC use by race-ethnicity.

IMPLICATIONS

Results from this analysis of NSFG data do not provide evidence that observed differences in LARC use by race-ethnicity represent socioeconomic disparities, and may assuage some concerns about reproductive coercion among women of color. Nevertheless, it is absolutely critical that providers use patient-centered approaches for contraceptive counseling that promote women's autonomy in their reproductive health care decision-making.

'If I went to my mom with that information, I'm dead': sexual health knowledge barriers among immigrant and refugee Somali young adults in Ohio

OBJECTIVES

Adequate knowledge of sexual health among young adults is a critical step in prevention of sexually transmitted diseases and maintenance of adult sexual health. Knowledge of specific barriers to accessing sexual health knowledge can help tailor approaches appropriately. The purpose of this paper was to identify sexual health knowledge barriers among Somali young adults in Ohio.

DESIGN

In-depth interviews were conducted with a convenience sample of 27 Somali young adults aged 18-25 years. Using a grounded theory approach, a semi-structured interview guide comprising open-ended questions and probes was utilized to collect data. Data were analyzed and coded using constant comparative analysis.

RESULTS

Findings revealed sexual health knowledge barriers in the following broad categories: religion, culture and stigma. Cultural and religious norms were deemed an important influence on the community norms largely impacting sexual health knowledge due to stigma and fear of judgment. Participants overcame barriers by seeking information from external sources such as doctors, Internet and peers.

CONCLUSION

Study findings support an approach that will address sexual health barriers in the Somali immigrant young community at multiple levels: individual, interpersonal and community levels. A collaborative effort across religious, cultural and educational setting is necessary to tailor approaches that meet the needs of the priority group.

Development and Validation of a Scale to Measure Adolescent Sexual and Reproductive Health Stigma: Results From Young Women in Ghana

Young women's experiences with sexual and reproductive health (SRH) stigma may contribute to unintended pregnancy. Thus, stigma interventions and rigorous measures to assess their impact are needed. Based on formative work, we generated a pool of 51 items on perceived stigma around different dimensions of adolescent SRH and family planning (sex, contraception, pregnancy, childbearing, abortion). We tested items in a survey study of 1,080 women ages 15 to 24 recruited from schools, health facilities, and universities in Ghana. Confirmatory factor analysis (CFA) identified the most conceptually and statistically relevant scale, and multivariable regression established construct validity via associations between stigma and contraceptive use. CFA provided strong support for our hypothesized Adolescent SRH Stigma Scale (chi-square p value < 0.001; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.06). The final 20-item scale included three subscales: internalized stigma (six items), enacted stigma (seven items), and stigmatizing lay attitudes (seven items). The scale demonstrated good internal consistency (α = 0.74) and strong subscale correlations (α = 0.82 to 0.93). Higher SRH stigma scores were inversely associated with ever having used modern contraception (adjusted odds ratio [AOR] = 0.96, confidence interval [CI] = 0.94 to 0.99, p value = 0.006). A valid, reliable instrument for assessing SRH stigma and its impact on family planning, the Adolescent SRH Stigma Scale can inform and evaluate interventions to reduce/manage stigma and foster resilience among young women in Africa and beyond.

Negotiating Discourses of Shame, Secrecy, and Silence: Migrant and Refugee Women's Experiences of Sexual Embodiment

In Australia and Canada, the sexual health needs of migrant and refugee women have been of increasing concern, because of their underutilization of sexual health services and higher rate of sexual health problems. Previous research on migrant women's sexual health has focused on their higher risk of difficulties, or barriers to service use, rather than their construction or understanding of sexuality and sexual health, which may influence service use and outcomes. Further, few studies of migrant and refugee women pay attention to the overlapping role of culture, gender, class, and ethnicity in women's understanding of sexual health. This qualitative study used an intersectional framework to explore experiences and constructions of sexual embodiment among 169 migrant and refugee women recently resettled in Sydney, Australia and Vancouver, Canada, from Afghanistan, Iraq, Somalia, South Sudan, Sudan, Sri Lanka, India, and South America, utilizing a combination of individual interviews and focus groups. Across all of the cultural groups, participants described a discourse of shame, associated with silence and secrecy, as the dominant cultural and religious construction of women's sexual embodiment. This was evident in constructions of menarche and menstruation, the embodied experience that signifies the transformation of a girl into a sexual woman; constructions of sexuality, including sexual knowledge and communication, premarital virginity, sexual pain, desire, and consent; and absence of agency in fertility control and sexual health. Women were not passive in relation to a discourse of sexual shame; a number demonstrated active resistance and negotiation in order to achieve a degree of sexual agency, yet also maintain cultural and religious identity. Identifying migrant and refugee women's experiences and constructions of sexual embodiment are essential for understanding sexual subjectivity, and provision of culturally safe sexual health information in order to improve well-being and facilitate sexual agency.

Negotiating Discourses of Shame, Secrecy, and Silence: Migrant and Refugee Women's Experiences of Sexual Embodiment

In Australia and Canada, the sexual health needs of migrant and refugee women have been of increasing concern, because of their underutilization of sexual health services and higher rate of sexual health problems. Previous research on migrant women's sexual health has focused on their higher risk of difficulties, or barriers to service use, rather than their construction or understanding of sexuality and sexual health, which may influence service use and outcomes. Further, few studies of migrant and refugee women pay attention to the overlapping role of culture, gender, class, and ethnicity in women's understanding of sexual health. This qualitative study used an intersectional framework to explore experiences and constructions of sexual embodiment among 169 migrant and refugee women recently resettled in Sydney, Australia and Vancouver, Canada, from Afghanistan, Iraq, Somalia, South Sudan, Sudan, Sri Lanka, India, and South America, utilizing a combination of individual interviews and focus groups. Across all of the cultural groups, participants described a discourse of shame, associated with silence and secrecy, as the dominant cultural and religious construction of women's sexual embodiment. This was evident in constructions of menarche and menstruation, the embodied experience that signifies the transformation of a girl into a sexual woman; constructions of sexuality, including sexual knowledge and communication, premarital virginity, sexual pain, desire, and consent; and absence of agency in fertility control and sexual health. Women were not passive in relation to a discourse of sexual shame; a number demonstrated active resistance and negotiation in order to achieve a degree of sexual agency, yet also maintain cultural and religious identity. Identifying migrant and refugee women's experiences and constructions of sexual embodiment are essential for understanding sexual subjectivity, and provision of culturally safe sexual health information in order to improve well-being and facilitate sexual agency.

Contraceptive Sterilization: Introducing A Couple Perspective to Examine Sociodemographic Differences in Use

CONTEXT

Most studies of contraceptive use have relied solely on the woman's perspective, but because men's attitudes and preferences are also important, analytic approaches based on couples should also be explored.

METHODS

Data from the 2006-2010 and 2011-2013 rounds of the National Survey of Family Growth yielded a sample of 4,591 men and women who were married or cohabiting with an opposite-sex partner and who had completed their intended childbearing. Respondents' reports of both their own and their partners' characteristics and behaviors were employed in two sets of analyses examining educational and racial and ethnic differences in contraceptive use: an individualistic approach (using multinomial logistic regression) and a couple approach (using multinomial logistic diagonal reference models).

RESULTS

In the full model using the individualistic approach, respondents with less than a high school education were less likely than those with at least a college degree to rely on male sterilization (odds ratios, 0.1-0.2) or a reversible method (0.4-0.5), as opposed to female sterilization. Parallel analyses limited to couples in which partners had the same educational levels (i.e., educationally homogamous couples) showed an even greater difference between those with the least and those with the most schooling (0.03 for male sterilization and 0.2 for a reversible method). When race and ethnicity, which had a much higher level of homogamy, were examined, the approaches yielded more similar results.

CONCLUSIONS

Research on contraceptive use can benefit from a couple approach, particularly when focusing on partners' characteristics for which homogamy is relatively low.

Barriers to modern contraceptive use in rural areas in DRC

Recent research in the Democratic Republic of Congo (DRC) has shown that over a quarter of women have an unmet need for family planning and that modern contraceptive use is three times higher among urban than rural women. This study focuses on the reasons behind the choices of married men and women to use contraception or not. What are the barriers that have led to low levels of modern contraceptive use among women and men in DRC rural areas? The research team conducted 24 focus groups among women (non-users of any method, users of traditional methods and users of modern methods) and husbands (of non-users or users of traditional methods) in six health zones of three geographically dispersed provinces. The key barriers that emerged were poor spousal communication, sociocultural norms (especially the husband's role as primary decision-maker and the desire for a large family), fear of side-effects and a lack of knowledge. Despite these barriers, many women in the study indicated that they were open to adopting a modern family planning method in the future. These findings imply that programming must address mutual comprehension and decision-making among rural men and women alike in order to trigger positive changes in behaviour and perceptions relating to contraceptive use.

Racial/Ethnic Differences in Young Women's Health-Promoting Strategies to Reduce Vulnerability to Sexually Transmitted Infections

PURPOSE

Young women of color in the United States are disproportionately affected by sexually transmitted infections (STIs). We characterize the protective behaviors used by young women to reduce their vulnerability to STI acquisition and examine how STI prevention strategies differ by race/ethnicity.

METHODS

From 2015 to 2016, women aged 13-24 years presenting to five Northern California family planning clinics were surveyed about their STI prevention strategies. The chi-squared tests and multivariable logistic regression identified associations between race/ethnicity and use of sexual health-promoting strategies.

RESULTS

Among 790 women, the most common strategies included condom use (67%), asking partners about STIs (47%), limiting sexual partners (35%), frequent STI screening (35%), and asking partners about other sexual partners (33%). Black, Hispanic, and Asian women had decreased odds of utilizing strategies before intercourse compared with white women (adjusted odds ratio [aOR]black: .25, confidence interval [.14-.47]; aORHispanic: .36, CI [.20-.65]; aORAsian: .44, CI [.23-.84]). Black women had decreased odds of using strategies requiring partner involvement (aORblack: .35, CI [.13-.92]). White women were more likely to report that providers discussed condoms (aOR: 2.53, CI [1.04-6.15]) and talked to partners about STIs (aOR: 2.56, CI [1.52-4.32]) compared with nonwhite women. Black and Hispanic women were more likely to feel very uncomfortable discussing lifetime sexual partners (aORblack: 4.26, CI [1.36-13.30] and aORHispanic: 5.35, CI [1.79-15.99]) and condom use (aORblack: 3.05, CI [1.14-8.15] and aORHispanic: 2.86, CI [1.11-7.35]) with providers.

CONCLUSIONS

Young women use diverse strategies to prevent STIs that vary by race/ethnicity. Providers can use these findings to improve sexual health counseling and promote equitable education and services.

Negotiating Collective and Individual Agency: A Qualitative Study of Young Women's Reproductive Health in Rural India

The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.

Black-White Differences in Sex and Contraceptive Use Among Young Women

This study examines black-white and other sociodemographic differences in young women's sexual and contraceptive behaviors, using new longitudinal data from a weekly journal-based study of 1,003 18- to 19-year-old women spanning 2.5 years. We investigate hypotheses about dynamic processes in these behaviors during early adulthood in order to shed light on persisting racial differences in rates of unintended pregnancies in the United States. We find that net of other sociodemographic characteristics and adolescent experiences with sex and pregnancy, black women spent less time in relationships and had sex less frequently in their relationships than white women, but did not differ in the number of relationships they formed or in their frequency or consistency of contraceptive use within relationships. Black women were more likely to use less effective methods for pregnancy prevention (e.g., condoms) than white women, who tended to use more effective methods (e.g., oral contraceptives). And although the most effective method for pregnancy prevention-long-acting reversible contraception (LARC)-was used more often by black women than white women, LARC use was low in both groups. In addition, black women did not differ from white women in their number of discontinuations or different methods used and had fewer contraceptive method switches. Further, we find that net of race and adolescent experiences with sex and pregnancy, women from more-disadvantaged backgrounds had fewer and longer (and thus potentially more serious) relationships, used contraception less frequently (but not less consistently), and used less effective methods (condoms) than women from more-advantaged backgrounds.

"Doctors are in the best position to know…": The perceived medicalization of contraceptive method choice in Ibadan and Kaduna, Nigeria

OBJECTIVES

The medicalization and clinic-based distribution of contraceptive methods have been criticized as barriers to increasing levels of contraceptive use in Nigeria and other settings; however, our understanding of how clients themselves perceive the contraceptive method decision-making process is very limited.

METHODS

Focus group discussions among men and women in Ibadan and Kaduna, Nigeria, were used to examine attitudes and norms surrounding contraceptive method decision-making in September and October of 2010.

RESULTS

Choosing a family planning method was presented as a medical decision: best done by a doctor who conducts clinical tests on the client to determine the best, side effect free, contraceptive method for each client. An absolute trust in health professionals, hospitals, and governments to provide safe contraception was evident.

CONCLUSION

The level of medicalization placed on contraceptive method choice by urban Nigerians is problematic, especially since a test that can determine what contraceptive methods will cause side effects in an individual does not exist, and side effects often do occur with contraceptive method use.

PRACTICE IMPLICATIONS

Provider and client education approaches would help to improve client involvement in contraceptive decision-making and method choice.

Conspiracy Beliefs About Birth Control: Barriers to Pregnancy Prevention Among African Americans of Reproductive Age

This article examines the endorsement of conspiracy beliefs about birth control (e.g., the belief that birth control is a form of Black genocide) and their association with contraceptive attitudes and behavior among African Americans. The authors conducted a telephone survey with a random sample of 500 African Americans (aged 15-44). Many respondents endorsed birth control conspiracy beliefs, including conspiracy beliefs about Black genocide and the safety of contraceptive methods. Stronger conspiracy beliefs predicted more negative attitudes toward contraceptives. In addition, men with stronger contraceptive safety conspiracy beliefs were less likely to be currently using any birth control. Among current birth control users, women with stronger contraceptive safety conspiracy beliefs were less likely to be using contraceptive methods that must be obtained from a health care provider. Results suggest that conspiracy beliefs are a barrier to pregnancy prevention. Findings point to the need for addressing conspiracy beliefs in public health practice.

Contraceptive choices and sexual health of Japanese women living in Australia: A brief report from a qualitative study

BACKGROUND

There is a lack of research focused specifically on the contraceptive and sexual health practices of Japanese women living in Australia.

OBJECTIVE

This paper reports findings from a cohort of migrant Japanese women who participated in a study of Australian women's understanding and experience of contraceptives.

METHODS

In-depth, open-ended interviews were conducted between August 2012 and June 2013 in New South Wales. Audio-recorded interviews of seven Japanese women were transcribed verbatim and analysed thematically.

RESULTS

The four prominent themes were the condom and withdrawal methods, varying attitudes to contraceptive practices, discussing contraception and sexual issues with general practitioners (GPs), and the unspoken topic of sexually transmissible infections (STIs).

DISCUSSION

Japanese migrants tend to choose the condom and withdrawal methods, which they perceive to be 'standard practice' in Japan. A greater understanding by Australian GPs of Japanese women's attitudes to contraception and sexual health issues could enhance the sexual health of Japanese women.

Contraception and Adolescent Males: An Opportunity for Providers

PURPOSE

To examine young men's awareness of emergency contraception (EC) and its association with their contraceptive decision-making contributions within a relationship.

METHODS

A convenience sample of English-speaking male patients aged 13-24 years were surveyed regarding their childbearing intentions, contraceptive awareness (including EC), perceived contraceptive knowledge, and communication about birth control with providers and within a relationship.

RESULTS

An ethnically diverse sample of adolescent males was recruited with a mean age of 18.9 years. Most had previously been sexually active (75%) and felt it was important to avoid pregnancy (84%) and 61% reported ever having spoken to a health care provider about birth control (other than condoms), but only 42% had heard of EC. Participants who had heard of EC were more likely to have spoken to a health care provider about contraception in the past (51.5% vs. 29.8%; p = .050), to feel they should participate in contraceptive decisions in a relationship (97.4% vs. 76.5%; p = .006), and to have discussed contraception with a partner (76.9% vs. 29.2%; p < .001).

CONCLUSIONS

Counseling young men about EC, as well as other methods of birth control, may empower them to become actively involved in contraceptive decisions within a relationship if they do not desire fatherhood.

Dual contraceptive method use and pregnancy intention among people living with HIV receiving HIV care at six hospitals in Thailand

BACKGROUND

Describe dual contraceptive method use and the intention to become pregnant of people living with HIV (PLHIV) and their partners in Thailand.

METHODS

From January 2008-March 2009, we systematically selected a cohort of PLHIV from PLHIV seeking care at five tertiary care hospitals and one community hospital to complete a questionnaire assessing sexual activity, intention to become pregnant, and contraceptive practices at baseline and 12 months after enrollment. Participants received short family planning messages every 2-3 months to promote the use of dual contraceptives and were offered family planning services.

RESULTS

A total of 1,388 PLHIV enrolled, their median age was 37 years (IQR 33-43), 898 (64.7%) had a steady partner, and 737 (53.1%) were male. Among those with a steady partner, 862 (96.0%) did not intend to become pregnant; 709 (82.3%) had sex during the previous 3 months, 683 (96.3%) used at least one contraceptive method, and 202 (29.6%) used dual contraceptive methods. Of the 317 PLHIV who used a single contraceptive method at baseline, 66 (20.8%) reported using dual methods at 12 months. Participants at two tertiary care hospitals where coordinators facilitated PLHIV referral between HIV and OB/GYN clinics were more likely than participants at the other hospitals to change from single method to dual method (p ≤ 0.03).

CONCLUSION

Few PLHIV in this study intended to become pregnant; however, only one-fourth used dual contraceptive methods. Integrating an assessment of the intention to become pregnant and strengthening the PLHIV referral systems in family planning services may contribute to higher rates of dual contraceptive use.

Mobile Technology for Improved Family Planning (MOTIF): the development of a mobile phone-based (mHealth) intervention to support post-abortion family planning (PAFP) in Cambodia

BACKGROUND

The objective of this paper is to outline the formative research process used to develop the MOTIF mobile phone-based (mHealth) intervention to support post-abortion family planning in Cambodia.

METHODS

The formative research process involved literature reviews, interviews and focus group discussions with clients, and consultation with clinicians and organisations implementing mHealth activities in Cambodia. This process led to the development of a conceptual framework and the intervention.

RESULTS

Key findings from the formative research included identification of the main reasons for non-use of contraception and patterns of mobile phone use in Cambodia. We drew on components of existing interventions and behaviour change theory to develop a conceptual framework. A multi-faceted voice-based intervention was designed to address health concerns and other key determinants of contraception use.

CONCLUSIONS

Formative research was essential in order to develop an appropriate mHealth intervention to support post-abortion contraception in Cambodia. Each component of the formative research contributed to the final intervention design.

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.

The influence of partnership on contraceptive use among HIV-infected women accessing antiretroviral therapy in rural Uganda

OBJECTIVE

The objective was to determine individual and dyadic factors associated with effective contraceptive use among human immunodeficiency virus (HIV)-infected women accessing antiretroviral therapy (ART) in rural Uganda.

STUDY DESIGN

HIV-infected women enrolled in the Uganda AIDS Rural Treatment Outcomes cohort completed questionnaires (detailing sociobehavioral characteristics, sexual and reproductive history, contraceptive use, fertility desires) and phlebotomy (October 2011-March 2013). We describe prevalence of effective contraceptive use (i.e., consistent condom use and/or oral contraceptives, injectable hormonal contraception, intrauterine device, female sterilization) in the previous 6 months among sexually active, nonpregnant women (18-40 years). We assessed covariates of contraceptive use using multivariable logistic regression.

RESULTS

A total of 362 women (median values: age 30 years, CD4 count 397 cells/mm(3), 4.0 years since ART initiation) were included. Among 284 sexually active women, 50% did not desire a(nother) child, and 51% had a seroconcordant partner. Forty-five percent (n=127) reported effective contraceptive use, of whom 57% (n=72) used condoms, 42% (n=53) injectables, 12% (n=15) oral contraceptives and 11% (n=14) other effective methods. Dual contraception was reported by 6% (n=8). Only "partnership fertility desire" was independently associated with contraceptive use; women who reported that neither partner desired a child had significantly increased odds of contraceptive use (adjusted odds ratio: 2.40, 95% confidence interval: 1.07-5.35) compared with women in partnerships where at least one partner desired a child.

CONCLUSIONS

Less than half of sexually active HIV-infected women accessing ART used effective contraception, of which 44% (n=56) relied exclusively on male condoms, highlighting a continued need to expand access to a wider range of longer-acting female-controlled contraceptive methods. Association with partnership fertility desire underscores the need to include men in reproductive health programming.

IMPLICATIONS STATEMENT

Less than half of sexually active HIV-infected women accessing ART in rural Uganda reported using effective contraception, of whom 44% relied exclusively on the male condom. These findings highlight the need to expand access to a wider range of longer-acting, female-controlled contraceptive methods for women seeking to limit or space pregnancies. Use of contraception was more likely when both the male and female partner expressed concordant desires to limit future fertility, emphasizing the importance of engaging men in reproductive health programming.

Racial and ethnic differences in contraceptive use among women who desire no future children, 2006-2010 National Survey of Family Growth

OBJECTIVE

To evaluate racial/ethnic differences in contraceptive use among women who do not desire future pregnancy.

STUDY DESIGN

We used the 2006-2010 National Survey of Family Growth to examine the associations between race/ethnicity and 1) use of any contraceptive method at last heterosexual intercourse and 2) effectiveness of contraceptive method used among women who stated that they did not desire any (more) children. We conducted multivariable logistic regression to assess the independent effect of race/ethnicity on these outcomes, adjusting for socio-demographic factors, reproductive characteristics, and indicators of healthcare access and utilization.

RESULTS

The study sample consisted of 2900 women, aged 15-44 years. The vast majority of women (91.2%) used contraception at last sex, although this varied significantly by race/ethnicity (p<.01). In the fully adjusted model controlling for demographic and reproductive characteristics as well as healthcare access, compared to whites, black women were significantly less likely to use any contraception at last sex (OR: 0.43; 95% CI: 0.27-0.73), while there was no significant difference for Hispanic women (OR: 0.95; 95% CI: 0.52-1.72). Among women who used a method at last sex, the type of contraceptive method varied significantly by race/ethnicity in bivariate analysis (p<.01), although most women (59%) used a highly effective method. In the fully adjusted model, racial/ethnic differences were no longer significant.

CONCLUSIONS

In this nationally representative cohort of women who report that they do not desire (more) children, black women were significantly less likely than white women to use any contraception at last intercourse; this difference did not appear to be due to differential access to health care.

IMPLICATIONS

Significant racial/ethnic differences exist in contraceptive use among women who have completed childbearing, which do not appear to be explained by differential socioeconomic status, reproductive characteristics or utilization of healthcare. Other factors, including social mobility and locus of reproductive control, that may contribute to these variations should be further explored.

Black-White Differences in Attitudes Related to Pregnancy Among Young Women

In this article, we use newly available data from the Relationship Dynamics and Social Life (RDSL) study to compare a wide range of attitudes related to pregnancy for 961 black and white young women. We also investigate the extent to which race differences are mediated by, or net of, family background, childhood socioeconomic status (SES), adolescent experiences related to pregnancy, and current SES. Compared with white women, black women generally have less positive attitudes toward young nonmarital sex, contraception, and childbearing, and have less desire for sex in the upcoming year. This is largely because black women are more religious than white women and partly because they are more socioeconomically disadvantaged in young adulthood. However, in spite of these less positive attitudes, black women are more likely to expect sex without contraception in the next year and to expect more positive consequences if they were to become pregnant, relative to white women. This is largely because, relative to white women, black women had higher rates of sex without contraception in adolescence and partly because they are more likely to have grown up with a single parent. It is unclear whether attitudes toward contraception and pregnancy preceded or are a consequence of adolescent sex without contraception. Some race differences remain unexplained; net of all potential mediators in our models, black women have less desire for sex in the upcoming year, but they are less willing to refuse to have sex with a partner if they think it would make him angry and they expect more positive personal consequences of a pregnancy, relative to white women. In spite of these differences, black women's desires to achieve and to prevent pregnancy are very similar to white women's desires.

Happiness about unintended pregnancy and its relationship to contraceptive desires among a predominantly Latina cohort

CONTEXT

Women frequently profess happiness about unintended pregnancies; such incongruence is associated with use of less effective contraceptive methods and inconsistent or incorrect method use. Yet, the methods women use may differ from those they desire.

METHODS

Data on 578 women were drawn from a prospective survey of postpartum women aged 18-44 recruited from three hospitals in Texas between 2012 and 2014. Jonckheere-Terpstra tests were used to compare women's feelings about a future pregnancy with their childbearing intentions. Fisher-Freeman-Halton tests compared distributions of contraceptive methods currently used and desired by women who professed happiness about a future unintended pregnancy, as well as distributions of desired methods by women's reported feelings.

RESULTS

The proportion of women who reported happiness about a future pregnancy was 59% among those intending to wait two or three years for another child, 46% among those intending to wait four or more years, and 36% among those intending to have no more children. Among women who professed happiness, a greater proportion desired to use a highly effective contraceptive method than were currently using one (72% vs. 15% among those intending no more children; 55% vs. 23% among those intending to wait at least four years; and 36% vs. 10% among those intending to wait two or three years). Across intention categories, the types of methods desired did not differ by whether women professed happiness or unhappiness.

CONCLUSIONS

Women who profess happiness about a future unintended pregnancy may nonetheless desire highly effective contraceptive methods.