Anrudh K. Jain

Fertility reduction and the quality of family planning services.

The purpose of this paper is to determine whether a focus on quality of family planning services is consistent with meeting demographic objectives. An analytical framework that links the six elements of quality with fertility is described. A review of existing literature and analysis suggest that improvements in quality of family planning services by enhancing the choice of contraceptive methods available in a country would increase the overall practice of contraception and thus would result in fertility reduction.

Breastfeeding: patterns, correlates, and fertility effects.

Paper based on data generated by the World Fertility Survey in 8 countries: Bangladesh, Indonesia, Sri Lanka, Jordan, Peru, Guyana, Colombia, and Panama. The authors address the following issues, among others: the prevalence and duration of breastfeeding; variations in the duration of breastfeeding among different subgroups, classified by age, parity, womans education, etc,; the key determinants of breastfeeding; and the effect of breastfeeding on fertility. The large majority of women in all the countries breastfed their last 2 children, the number who did not ranging from 2 to 18%. Duration ranged from 9 months (Panama) to 29 months (Bangladesh). Key determinants were womens education, place of residence, husbands occupation, and survival status of the child--consistent for all 8 countries. Women with more education and those living in urban areas breastfeed for shorter periods. Sex of child, age and parity of mother, and mothers work experience showed no independent effect on duration of breastfeeding. Although breastfeeding is not used for family limitation, the possibility that it is used to prolong birth intervals cannot be ruled out. Average length of last closed birth interval increased with prolonged breastfeeding in all 8 countries. 1 month of breastfeeding adds an average of 0.4 months to the birth interval, although there was considerable variation among the countries. To what extent these variations may be due to differences in reporting errors or to other factors could not be determined.

Demographic aspects of lactation and postpartum amenorrhea

Interrelations between lactation and post-partum amenorrhea are studied from the reports of about 5,000 married women included in a 1966 Follow-up Survey of Acceptors of an Intrauterine Device (IUD) in Taiwan. The length of post-partum amenorrhea and of breastfeeding are positively associated. On an average, breastfeeding delayed the resumption of menstruation by about 7 months. The association between lactation and amenorrhea is not accounted for by differences in mother’s age, parity, education and her place of residence. A multiple regression analysis suggests that (1) age affects amenorrhea both directly and through lactation, (2) parity has no independent effect on either lactation or amenorrhea, and (3) education and place of residence affect amenorrhea mainly through the cultural variations in the practice of breastfeeding.

The impact of the quality of family planning services on contraceptive use in Peru

Through linkage of a Demographic and Health Survey to a situation analysis, this article explores whether current contraceptive use in Peru is affected by the service environment in which a woman resides. The investigation focuses explicitly on the impact of the quality of family planning services and finds that, net of personal and household characteristics, a significant, albeit small, effect exists for one specification of quality in the total sample and for the other specification a nearly significant (p = .053) effect exists. The analysis reveals that contraceptive prevalence would be 16 to 23 percent greater if all women lived in a cluster with the highest quality of care compared with the lowest. Methodological problems that arise in measuring quality of care at the cluster level and in linking quality to individual contraceptive use are also addressed.

THE EfFECT OF FEMALE EDUCATION ON FERTILITY: A SIMPLE EXPLANATION

This paper investigates the structure of the relationship between female education and fertility. It is based on data published in First Country Reports of the World Fertility Surveys for eleven countries—Costa Rica, Colombia, Dominican Republic, Panama, Fiji, Korea, Malaysia, Pakistan, Sri Lanka, Thailand, and Indonesia. The cumulative marital fertility of educated women is shown to be similar in different settings. A lack of uniformity in the education and fertility relationship including the curvilinear nature of this relationship observed across countries is shown to be attributable to marked differences between countries in the average fertility of women with no education rather than to the presumed differences in the average fertility of the educated women. The structure of the relationship is shown to be similar across several developing countries. This analysis suggests that advancement in female education can be expected to influence fertility behavior even without simultaneous changes in other factors such as increasing opportunity for participation in the paid labor force in the modem sector.

Should Eliminating Unmet Need for Contraception Continue to be a Program Priority

This study examined the implications of family planning (FP) policy and program emphasis on fulfilling unmet need in Peru. Data were obtained from the 1991-92 Demographic and Health Survey and a 1994 follow-up survey conducted in 2 regions. The sample included 1093 married women. Findings indicate that the proportion who wanted no more children and reported contraceptive use were similar in 1991-92 and 1994. The proportions of women with unmet need were 18% and 17% respectively in 1991-92 and 1994. FP programs appear to have had little impact on unmet need or prevalence; but women switch between unmet need groups. By 1994 72% of the 18% with unmet need in 1991-92 had their need satisfied. 23% shifted reproductive intentions and had more children. 39% of women in 1991-92 had unmet need for a modern method but only 17% had their need met by 1994. In 1991-92 43% with unmet need no longer had unmet need in 1994. In 1991-92 82% were without unmet need. 12% without unmet need in 1991-92 had unmet need in 1994. 61% did not have unmet need in 1991-92 but 14% did have unmet need for modern contraception in 1994. Simulations show that avoidance of unintended pregnancy among women without unmet need would reduce unintended pregnancy to 6% from 17%. Programs should emphasize willing contraceptors. A second program priority should be on noncontracepting women who desire spacing or limiting. FP programs that rely on a client-oriented approach and support the Cairo recommendations should not focus on changing womens reproductive intentions.

Cigarette smoking, use of oral contraceptives, and myocardial infarction.

The excess risk of nonfatal myocardial infarction among users of oral contraceptives observed in England and Wales can be explained in terms of the high proportion of smokers in the study population. Among nonsmokers, the relative risk associated with the use of oral contraceptives is estimated to be 2 to 1, which is not statistically significant (P = 0.28, Fishers exact probability test). The present analysis suggests that smoking be considered as another contraindication for the prescription of oral contraceptives. The results further indicate that those women who smoke as well as use oral contraceptives and are interested in reducing the risk of nonfatal mycardial infarction should be encouraged to give up smoking. The relative risk of nonfatal myocardial infarction associated with the use of oral contraceptives observed in a society can vary between 0.9 to 1 and 11.7 to 1, depending upon the proportion of smokers. From the public health point of view, the reduction in the excess risk of nonfatal myocardial infarction achieved by eliminating smoking is estimated to be much more than can be achieved by eliminating the use of oral contraceptives.

Contraception with long acting subdermal implants: I. An effective and acceptable modality in international clinical trials

This paper presents results of a double blind, multi-centered and multi-national study of two progestin only subdermal implants used for contraception. A regimen of six capsules of levonorgestrel (Ng) used by 492 women had a net cumulative 12-month pregnancy rate of 0.6 percent and a continuation rate of 74.6 percent. 498 women used six capsules of norgestrienone (R2010) and experienced a net cumulative 12-month pregnancy rate of 3.5 percent and a continuation rate of 79.4 percent. The difference in the pregnancy rate was significant at P less than 0.01, while there was no significant difference in the continuation rates. Menstrual problems were the principal reason for termination of the levonorgestrel regimen, accounting for approximately half of all terminations. There were significantly fewer menstrual problems among users of the norgestrienone (R2010) capsules; the net cumulative 12-month termination rate for this reason was 4.3 percent. Results are compared with continuation and termination rates for acceptors of the Copper T 200 at the same clinics. The low pregnancy rate and reasonably high continuation rate of the norgestrel implants coupled with the fact that the expected effective lifetime of a set of capsules is of the order of 3-5 years appears to warrant further development of this contraceptive regimen.

Indicators of Mobility, Socio-Economic Vulnerabilities and HIV Risk Behaviours Among Mobile Female Sex Workers in India

This paper examines the relationship between indicators of mobility, socio-economic vulnerabilities, and HIV risk behaviours among 5,498 mobile female sex workers (FSWs) living in the four high HIV prevalence states in India. Female sex workers with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they experienced physical violence, and consumed alcohol prior to sex. Further, FSWs with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they had inconsistent condom use in sex with clients, even after controlling for several demographic characteristics and socio-economic vulnerabilities including experiences of violence. Additionally, short duration visits and visit to the Jatra (religious fairs) places found to have significant association with their inconsistent condom use in sex with clients as well as continuation of sex despite having STI symptoms. These findings suggest the need for screening FSWs for higher degree of mobility and to mobilize them to form community networks so as to deal with violence, reduce alcohol use and promote consistent condom use along the routes of mobility. HIV prevention interventions aimed at FSWs require an increased attention to address the socio-economic vulnerabilities including alcohol use, with particular emphasis on those FSWs who are on the move in India and elsewhere.

Safety and effectiveness of intrauterine devices

Abstract The life-table analysis of about 16,000 first insertions of the Copper T Model 200 (TCu-200) in the United States indicates that about 58.5 percent of these women terminated the use of the TCu-200 by the end of three years following the insertion. This includes about 6.6 percent who became pregnant during this period. The results of the TCu-200 are compared with the Copper 7 and with Dalkon Shields from two double-blind studies of these devices. In the end, the index — The Mortality Benefit Ratio — defined in terms of the number of deaths per 1000 births averted, is used to compare the relative risks and benefits associated with various forms of contraception. Based on the experience in the United States, the values of the Mortality Benefit Ratio indicate that IUDs are at least as safe, if not safer, than other forms of contraception currently available.