Showing papers in "Studies in Family Planning in 2003"

Age and economic asymmetries in the sexual relationships of adolescent girls in sub-Saharan Africa.

Abstract: This literature review assesses the extent of age mixing and economic transactions in the sexual relationships of adolescent girls in sub-Saharan Africa and the behavioral dynamics of girls and men involved in these partnerships. The examination of more than 45 quantitative and qualitative studies finds that relationships with older partners and those that involve economic transactions are common and that these asymmetries are associated with unsafe sexual behaviors and increased risk of HIV infection. Although the reasons that adolescent girls engage in sexual relationships with older men are varied, receipt of financial benefits is a major motivation. The literature presents evidence that girls have considerable negotiating power over certain aspects of sexual relationships with older men, including partnership formation and continuation; however, they have little control over sexual practices within partnerships, including condom use and violence. The review discusses directions for further research and the implications of current knowledge for future interventions.

How Gender Roles Influence Sexual and Reproductive Health Among South African Adolescents

Abstract: Although the literature on Africa increasingly adopts a gendered approach to sexual and reproductive health issues, few studies have addressed adolescent pregnancy and parenthood in such a framework. This article examines links between gender ideology or gender roles and the social impact of adolescent childbearing in the lives of rural and urban adolescents in KwaZulu/Natal, South Africa. It employs a triangulated research methodology (focus-group discussions, narrative role playing and discussions, and questionnaires and in-depth interviews) to inform an analysis of adolescents' notions of male and female gender ideals. This analysis forms the basis for an exploration of the potential influence of adolescent childbearing on young peoples' lives and factors that shape their sexual and reproductive well-being. Results indicate that gender ideals are grounded in traits that reinforce poor sexual negotiation dynamics and behavioral double standards and that place adolescents at risk for early pregnancy and other sexual and reproductive health complications. Overall, adolescent parenthood is viewed negatively by participants of both sexes because it compromises personal, professional, and financial aspirations. Compared with its effect on boys, parenthood has a disproportionate (and highly negative) impact on girls that is directly linked to gender-based inequities. The article addresses the research and policy implications of these findings.

Estimating induced abortion rates: a review.

Abstract: Legal abortions are authorized medical procedures, and as such, they are or can be recorded at the health facility where they are performed. The incidence of illegal, often unsafe, induced abortion has to be estimated, however. In the literature, no fewer than eight methods have been used to estimate the frequency of induced abortion: the "illegal abortion provider survey," the "complications statistics" approach, the "mortality statistics" approach, self-reporting techniques, prospective studies, the "residual" method, anonymous third party reports, and experts' estimates. This article describes the methodological requirements of each of these methods and discusses their biases. Empirical records for each method are reviewed, with particular attention paid to the contexts in which the method has been employed successfully. Finally, the choice of an appropriate method of estimation is discussed, depending on the context in which it is to be applied and on the goal of the estimation effort.

The quality of family planning programs: concepts, measurements, interventions, and effects.

Abstract: This study reviews the major research and interventions concerning readiness and quality of care in family planning programs. It has three aims: to identify and describe the principal methodological research including conceptual frameworks, perspectives, and tools for measuring and improving quality; to describe the results from various intervention studies; and to assess what is known about the effect of such interventions. The review suggests that interventions that improve client-provider interactions show the greatest promise. Good quality of care results in such positive outcomes as clients' satisfaction, increased knowledge, and more effective and longer use of contraceptives. Rigorously documented evidence of the effects of interventions is sorely needed. The review indicates areas requiring additional research.

Trends and determinants of contraceptive method choice in Kenya.

Abstract: This study uses data from the 1989, 1993, and 1998 Kenya Demographic and Health Surveys to examine trends and determinants of contraceptive method choice in Kenya. The analysis, based on two-level multinomial regression models, shows that, over time, the use of modern contraceptive methods, especially long-term methods, is higher in urban than in rural areas, whereas the pattern is reversed for traditional methods. Use of barrier methods among unmarried women is steadily rising, but the levels remain disappointingly low, particularly in view of the HIV/AIDS epidemic in Kenya. One striking result from this analysis is the dramatic rise in the use of injectables. Of particular program relevance is the notably higher levels of use of injectables among rural women, women whose partners disapprove of family planning, uneducated women, and those less frequently exposed to family planning media messages, compared with their counterparts who have better access to services and greater exposure to family planning information.

Associations of mass media exposure with family planning attitudes and practices in Uganda.

Abstract: This study examines the associations between multimedia behavior change communication (BCC) campaigns and women's and men's use of and intention to use modern contraceptive methods in target areas of Uganda. Data are drawn primarily from the 1997 and 1999 Delivery of Improved Services for Health (DISH) evaluation surveys, which collected information from representative samples of women and men of reproductive age in the districts served by the DISH project. Additional time-trend analyses rely on data from the 1995 Uganda Demographic and Health Survey. Logistic regressions are used to assess the associations between BCC exposure and family planning attitudes and practices, controlling for individuals' background characteristics. To minimize the biases of self-reported exposure, the analyses also explore cluster-level indexes of the penetration of BCC messages in the community. Results indicate that exposure to BCC messages was associated with increased contraceptive use and intention to use. Some evidence of self-reported bias is found, and the pathways to fertility-related behavioral change appear different for women and men.

Gender‐role Attitudes among Egyptian Adolescents

Abstract: Using nationally representative survey data, this study explores gender-role attitudes among unmarried adolescents aged 16-19 in Egypt, a society characterized by distinct and often segregated roles for men and women. Adolescents' views about desirable qualities in a spouse as well as more direct indicators of gender-role attitudes are examined, including opinions about whether wives should defer to their husbands, share in household decision making, and have the responsibility for performing domestic tasks. The findings regarding spousal characteristics reflect strong gender differentiation. Girls and boys provide divergent profiles of an ideal spouse, profiles that reflect traditional gender roles. Girls are significantly less likely than boys to favor educational inequality between spouses, however. Neither boys nor girls have egalitarian gender-role attitudes, although girls are significantly more likely to express less traditional attitudes. Multivariate analyses indicate that girls' and boys' attitudes do not vary consistently and significantly by socioeconomic background; in particular, increased schooling does not always promote egalitarian attitudes. The implications of these findings are discussed.

The proximate determinants of the decline to below-replacement fertility in Addis Ababa Ethiopia.

Abstract: Between 1990 and 2000, the total fertility rate (TFR) in Ethiopia declined moderately from 6.4 to 5.9 children per woman of reproductive age. During the same period, the TFR in the capital city of Addis Ababa declined from 3.1 to 1.9 children per woman. Even more striking than the magnitude of this decline is that it occurred in the absence of a strong and effective national family planning program. In this study, the components of this fertility decline are identified using the Bongaarts framework of the proximate determinants of fertility. The results of a decomposition analysis indicate that a decrease in the age-specific proportions of women who are married, followed by an increase in contraceptive use are the most important mechanisms by which fertility has declined in Addis Ababa. Poor employment prospects and relatively high housing costs are likely factors that encourage couples to delay marriage and reduce marital fertility.

Inequality and changes in women's use of maternal health-care services in Tajikistan.

Abstract: Using recently available survey data for Tajikistan, this study explores changes in the pattern of maternal health care during the last decade and the extent to which inequalities in access to that care have emerged. In particular, the links between poverty and women's educational status and the use of maternal health-care services are investigated. The survey findings demonstrate a significant decline in the use of maternal health-care services in Tajikistan since the country gained independence from the Soviet Union in 1991. They show changes in the location of delivery and the person providing assistance, with a clear shift away from giving birth in a medical facility toward giving birth at home. More than two-fifths of all women who gave birth in the year prior to the survey delivered their baby at home. Women from the poorest quintile are three times more likely than women from the richest quintile to undergo a home delivery without a trained assistant.

Rural Indian women's care-seeking behavior and choice of provider for gynecological symptoms.

Abstract: This study uses data from the India National Family and Health Survey–2 conducted in 1998–99 to investigate the level and correlates of care-seeking and choice of provider for gynecological symptoms among currently married women in rural India. Of the symptomatic women surveyed 31 percent sought care overwhelmingly from private providers (70 percent). Only 8 percent of women consulted frontline paramedical health workers. Care-seeking behavior and type of providers consulted varied significantly across different Indian states. Significant differentials in care-seeking by age caste religion education household wealth and women’s autonomy suggest the existence of multiple cultural economic and demand-side barriers to care-seeking. Although socially disadvantaged women were less likely than better-off women to consult private providers the majority of even the poorest uneducated and lower-caste women consulted private providers. Geographical access to public health facilities had no significant association with choice of provider whereas access to private providers had only a moderately significant association with that choice. The predominance of use of private services for self-perceived gynecological morbidity warrants the inclusion of private providers in the national reproductive health strategy to enhance its effectiveness. (authors)

Factors Influencing Young Malians' Reluctance to Use Hormonal Contraceptives

Abstract: During a qualitative evaluation of three peer-education programs in urban Mali, young people stated that they were wary of using either the pill or injectable contraceptives because they believed that these methods would make them sterile. Unmarried women's contraceptive decisionmaking was not primarily driven by a current need to limit fertility, but rather by a future need to maximize it in order to gain status through childbearing in their marital households. Further interviews explored notions of conception, menstruation, and the perceived action of hormonal methods on the reproductive system. Findings revealed that menstrual disruption (in the form of amenorrhea or prolonged bleeding) appeared to have dire repercussions, including accusations of witchcraft and immoral behavior that could result in a woman's being divorced or in her husband's acquiring an additional wife. The social consequences of side effects were perceived to be more important than their biological manifestations, and together with the fear of sterility, resulted in a preference for the condom.

Adolescents in Vietnam: looking beyond reproductive health.

Abstract: The research that has been conducted to date on Vietnamese adolescents has focused on unprotected and unsanctioned sexual activity and its health consequences, specifically abortion and sexually transmitted diseases, especially HIV. The question we pose in this article is whether this concern is warranted. Is the population community justified in limiting research on this population to early sexual activity and HIV risk? Even if the sexual behavior of young people can be considered problematic, are there perhaps other aspects of young peoples' lives to which more attention should be devoted? The literature on adolescent sexual behavior in Vietnam is reviewed and data on premarital sex and reproductive behavior are analyzed from a 1999 survey conducted in six provinces among nearly 1,500 adolescent boys and girls aged 15-22. Descriptive data on schooling and work are included in order to put the information on sexual activity in perspective. The data analysis reveals that, at least currently, the sexual behavior of unmarried adolescents in Vietnam is not what jeopardizes their health and well-being.

Inconsistent reporting of female genital cutting status in northern Ghana: explanatory factors and analytical consequences.

Abstract: Although many cross-sectional social surveys have included questions about female genital cutting status and correlated personal characteristics, no longitudinal studies have been launched that permit investigation of response biases associated with such surveys. This study draws upon the findings of a longitudinal study of women aged 15 to 49 in rural northern Ghana. The self-reported circumcision status of women interviewed in 1995 was compared with the status they reported when they were interviewed again in 2000 after the government began enforcing a law banning the practice and public information campaigns against it were launched. In all, 13 percent of respondents who reported in 1995 that they had been circumcised stated that they had not been circumcised in the 2000 reinterview; this inconsistency reached 50 percent for the youngest age group. Analysis shows that women who said they had not been circumcised are significantly younger, more likely to be educated, and less likely to practice traditional religion than are women who reported that they were circumcised. Factors that may explain these correlates of denial are discussed, and implications for research are reviewed.

Determinants of contraceptive method choice in rural Tanzania between 1991 and 1999.

Abstract: Four pooled Demographic and Health Survey data sets are used to examine the determinants of contraceptive method choice in rural Tanzania for the period from 1991 to 1999. The individual data are linked to facility surveys conducted in the same communities so that the impact of Tanzania's family planning program can be examined. The focus of the study is an examination of the effect on method choice of the three major components of Tanzania's family planning program: logistical support, trained providers, and communications programs. The statistical methods employed correct for the potential endogeneity of family planning message recall. Simulations are used to quantify the impact of the important policy variables. All three components of the program are shown to have had an impact on modern method choice.

Abortion Service Provision in South Africa Three Years After Liberalization of the Law

Abstract: In 1996, South Africa introduced legislation that liberalized women's access to termination of pregnancy. This study presents the findings of a survey undertaken to describe the availability and accessibility of abortion services in 1999, three years after the law was passed. All facilities that had been officially designated to perform these services were contacted by telephone to determine whether they were providing the services, their capacity, whether they were performing second-trimester as well as first-trimester terminations, and how long women had to wait for these services. Nationally, 292 facilities had been designated, but in 1999 only 32 percent were functioning. Of the functioning facilities, 27 percent were in the private sector. Mapping of available services indicated that substantial parts of the country were entirely without such services. Half of the country's induced abortions were being performed in Gauteng province, although only 19 percent of women of reproductive age were living there. This finding indicates that service provision in other provinces was inadequate or lacking. Although in the first years following the new legislation efforts were made to establish abortion services, this study reveals gross inequality in service availability. Strategies for improving coverage are suggested.

Contraceptive use in a changing service environment: evidence from Indonesia during the economic crisis.

Abstract: In the late 1990s, most Southeast Asian countries experienced substantial economic downturns that reduced social-sector spending and decreased individuals' spending power. Data from Indonesia were collected in 1997 (just before the crisis) and in 1998 (during the crisis) that are used in this study to examine changes in the contraceptive supply environment and in women's choices regarding contraceptive use. Despite substantial changes in providers' characteristics during the first year of the crisis, no statistically significant differences are found between 1997 and 1998 in overall levels of prevalence, in unmet need, or in method mix. Women's choices regarding source of contraceptive supplies, however, changed considerably over the period. Changes in the contraceptive supply environment are linked here to changes in women's choice of source of supply, and a number of providers' characteristics are found to be significantly associated with women's choices in this regard.

Does use of the calendar in surveys reduce heaping

Abstract: This study examines heaping of reported durations of three postpartum variables in five countries based on two methods of data collection in retrospective surveys. Two Demographic and Health Surveys were conducted for each of the countries, one that used a five-year month-by-month calendar to record the durations and a subsequent survey in which duration information was collected from simple questions in the body of the questionnaire. Heaping indexes were calculated for breastfeeding, amenorrhea, and abstinence at six, 12, 18, and 24 months postpartum. Use of the calendar was associated with a significant reduction in the proportion of heaped responses for both breastfeeding and amenorrhea, and the effect increased for longer durations. To obtain more accurate information about these variables, the authors recommend the use of the calendar.

Contraceptive use before and after marriage in Shanghai.

Abstract: Data from a cohort study of 7,336 newly married fertile couples conducted between 1987 and 1995 were used to analyze contraceptive method choice, switching, and discontinuation in two districts of Shanghai. Twelve percent of couples reported that they had had sexual intercourse before marriage. Only one-third of those exposed to premarital risk of conception were protected by some form of contraception, mostly by withdrawal and periodic abstinence. As a consequence, a majority of these couples conceived, prompting rapid marriage in most cases and induced abortion among one-fourth of them. After marriage, about half of the couples used contraceptives to postpone the birth of their first child, but of these, 40 percent experienced an unintended pregnancy. Method choice was dominated by condoms, withdrawal, and abstinence. After the birth of their first child, almost all couples (98 percent) adopted contraceptives, but one-third of them used ineffective methods. Failure and discontinuation rates were high, giving rise to a high incidence of induced abortion. Increasing numbers of couples switched to the IUD, and this was the preferred method for the majority by the third year following childbirth. These results suggest that wider method choice that includes hormonal contraceptives should be provided to meet couples' needs in Shanghai and that the family planning program's attention should be focused specifically on sexually active unmarried individuals and on the availability of postpartum services.

Cost-effectiveness of USAID's regional program for family planning in West Africa.

Abstract: Between 1994 and 1996, the United States Agency for International Development (USAID) closed 23 country missions worldwide, of which eight were in West and Central Africa. To preserve United States support for family planning and reproductive health in four countries in that region, USAID created a subregional program through a consortium of US-based groups that hired mainly African managers and African organizations. This study assesses cost-effectiveness of the program through an interrupted time-series design spanning the 1990s and compares cost-effectiveness in four similar countries in which mission-based programs continued. Key indicators include costs, contraceptive prevalence rates, and imputed "women-years of protection." The study found that, taking into account all external financing for population and family planning, the USAID West Africa regional approach generated women-years of protection at one-third the cost of the mission-based programs. This regional approach delivered family planning assistance in West Africa cost-effectively, and the findings suggest that regional models may work well for many health and population services in small countries.