Barbara Janowitz

The value of contraception to prevent perinatal HIV transmission.

Objective: The objective of this study was to highlight the value of preventing unintended pregnancies among HIV-infected women as a strategy to prevent perinatal HIV transmission. Goal: The goal of this study was to assess the cost-effectiveness of family planning programs to avert HIV-positive births with the current programmatic emphasis: prenatal care services that provide and promote nevirapine for prevention of mother-to-child transmission of HIV. Study Design: Cost-effectiveness analyses were conducted from the health system perspective during 1 year with a hypothetical sub-Saharan African population. Expected program costs were combined with number of HIV-positive births averted for each strategy. Results: At the same level of expenditure, the contraceptive strategy averts 28.6% more HIV-positive births than nevirapine for prevention of mother-to-child transmission of HIV. Conclusions: Increasing contraceptive use among nonusers of contraception who do not want to get pregnant is cost-effective and is an equally important strategy to prevent perinatal transmission as prenatal care programs that provide and promote nevirapine to HIV-infected mothers.

Menstruation Requirements: A Significant Barrier to Contraceptive Access in Developing Countries

A review of surveys from Ghana, Kenya, Cameroon, Jamaica, and Senegal suggests that the requirement that women seeking hormonal contraception and IUDs should present for family planning services when menstruating represents a significant but unrecognized barrier to contraceptive access. Non-menstruating clients are instructed to return to the family planning facility at the onset of menses and often are not provided with a provisional barrier method. The time and money involved in a return trip to the clinic may prevent poor women from making another visit and others may become pregnant while awaiting their menses. A total of 10 studies conducted in these 5 developing countries found that 41-92% of non-menstruating family planning clients were denied contraceptive services. Providers cited 4 rationales for this practice: 1) the presence of menstruation is a cheap, effective proxy for a pregnancy test; 2) methods such as the IUD and oral contraceptives are best initiated during menses; 3) menstruation requirements prevent the use of contraceptives for self-induced abortion; and 4) most clients know they should present for services when they are menstruating. Although some aspects of the menstruation requirement are rooted in a concern for womens health, the overall effect of such a restriction is to deny women the right to contraception and to place them at risk of an unwanted pregnancy. Simple checklists aimed at ruling out the possibility of pregnancy could be used in non-menstruating women.

Fertility and contraceptive use among young adults in Harare, Zimbabwe.

In 1986, a survey of young adults aged 14-24 in Harare, Zimbabwe obtained information about their knowledge, attitudes, and sexual behavior. Most adolescent childbearing took place within marriage, although sexual intercourse was generally initiated before marriage. Knowledge of family planning was high, but contraceptive use lagged behind knowledge. Fewer than half of the respondents had talked to an elder about family planning, sex, or pregnancy. Fourteen percent of young women who were unmarried at the time of first intercourse used contraceptives, compared to 18 percent of young unmarried men. Current contraceptive use among sexually active unmarried youths was 36 percent among women and 29 percent among men. One consequence of low contraceptive use was a high number of unwanted premarital pregnancies. Twenty-nine percent of the women had been pregnant; those not married at the time they got pregnant generally got married soon after. Of the girls who got pregnant while in school, 90 percent had to drop out of school. A second consequence of low contraceptive use is an increased risk of transmission of STDs and AIDS among the youth of Harare.

Cesarean section in Brazil

Delivery practices are examined at nine hospitals in the southern part of Brazil. All hospitals show similar practices, with approximately 75% of deliveries to private patients being abdominal compared with 40% to insured patients and less than 25% to indigent patients. Further examination of the data for one of these hospitals showed that medical indications for cesarean section could not explain these variations. A much higher percentage of cesarean deliveries for private patients than for other women were scheduled in advance of hospitalization. Financial considerations play an important role in these practices.

Contraceptive needs of female sex workers in Kenya – A cross-sectional study

Background and objectives Female sex workers (FSWs) are thought to be at heightened risk for unintended pregnancy, although sexual and reproductive health interventions reaching these populations are typically focused on the increased risk of sexually transmitted infections. The objective of this study of FSWs in Kenya is to document patterns of contraceptive use and unmet need for contraception. Methods This research surveys a large sample of female sex workers (N = 597) and also uses qualitative data from focus group discussions. Results The reported level of modern contraceptives in our setting was very high. However, like in other studies, we found a great reliance on male condoms, coupled with inconsistent use at last sex, which resulted in a higher potential for unmet need for contraception than the elevated levels of modern contraceptives might suggest. Dual method use was also frequently encountered in this population and the benefits of this practice were clearly outlined by focus group participants. Conclusion These findings suggest that the promotion of dual methods among this population could help meet the broader reproductive health needs of FSWs. Furthermore, this research underscores the necessity of considering consistency of condom use when estimating the unmet or undermet contraceptive needs of this population.

Reasons for the Low Level of IUD Use in El Salvador

While the IUD is a safe and cost-effective method use is very low in some countries and the reason for this are not well understood. To examine the reasons that the IUD is little used in El Salvador data were collected in 1999 via three techniques. In-depth interviews were conducted with 30 providers; simulated clients made a total of 40 clinic visits; and 10 focus groups were conducted separately with sterilized women current or past IUD users of other clinical FP methods. Most FP clients who had never used an IUD reported a negative impression of the method mainly because of fear resulting from rumors and myths they had heard. In contrast nearly all IUD users viewed the method positively. Most providers interviewed reported a positive attitude. Providers agreed that rumors and myths are the biggest barrier to IUD promotion yet simulated clients reported that providers spontaneously tried to dispel myths in only half of visits. Most providers said they discussed the IUD with clients but many focus-group participants said they received information only on pills and injectables. According to simulated clients providers spontaneously mentioned pills and injectables more than any other method. While 23 of the 30 providers interviewed had been trained in IUD insertion many felt they did not have enough practical experience. Three main barriers impede IUD use in El Salvador: rumors and myths about the method; insufficient attention to the method during counseling sessions; and insufficient provider experience with it. (authors)

Management and treatment of diarrhea in Honduran children: Factors associated with mothers' health care behaviors

Data from the 1984 National Maternal-Child Health and Family Planning Survey in Honduras showed that one fifth (n = 711) of the children under five had experienced diarrhea on the day of the interview or the two days preceding the interview. The health care behaviors of the mothers of these children and the factors associated with these behaviors were the focus of this study. Only 22% of the mothers consulted medical personnel concerning the diarrhea episode; 74% treated their children with some type of medication while only 17% of the children received the recommended treatment, oral rehydration therapy. Most children were treated inappropriately, often receiving a combination of antibiotics, antidiarrheals and other drugs. Bivariate and multivariate analyses showed that the variables that most consistently predicted any and all three of the behaviors were the childs age and the severity of symptoms. Mothers of children two years and older were less likely to consult or use ORT than mothers of children 6-23 months of age. Mothers whose childrens diarrhea had lasted three or more days or who were vomiting were usually twice as likely to consult, give any type of treatment, or give ORT than mothers whose children had diarrhea for fewer days or who were not vomiting.

Breast-feeding and child survival in Egypt.

In a retrospective study the impact of breastfeeding on the survival probabilities of children born to women in hospitals in Cairo is estimated. Early cessation of breastfeeding is associated with higher mortality and the effects are more severe the lower the educational level of the mother. (Authors)

Bridging emergency contraceptive pill users to regular contraception: results from a randomized trial in Jamaica

BACKGROUND Emergency contraception research has shifted from examining the public health effects of increasing access to emergency contraceptive pills (ECPs) to bridging ECP users to a regular contraceptive method as a way of decreasing unintended pregnancies. STUDY DESIGN In a randomized controlled trial in Jamaica, we tested a discount coupon for oral contraceptive pills (OCPs) among pharmacy-based ECP purchasers as an incentive to adopt (i.e., use for at least 2 months) this and other regular contraceptive methods. Women in the intervention and control arms were followed up at 3 and 6 months after ECP purchase to determine whether they adopted the OCP or any other contraceptive method. Condom use was recorded but was not considered a regular contraceptive due to its inconsistent use. RESULTS There was no significant difference in the proportion of women who adopted the OCP, injectable or intrauterine device in the control group or the intervention group (p=.39), and only 14.6% of the sample (mostly OCP adopters) used one of these three methods. Condom use was high (44.0%), demonstrating that ECP users were largely a condom-using group. CONCLUSIONS The discount coupon intervention was not successful. Although a small proportion of ECP users did bridge, the coupon did not affect the decision to adopt a regular contraceptive method. The study highlighted the need for bridging strategies to consider womens reproductive and sexual behaviors, as well as their context. However, in countries like Jamaica where HIV/AIDS is of concern and condom use is appropriately high, bridging may not be an optimal strategy.

What happens to contraceptive use after injectables are introduced? An analysis of 13 countries.

CONTEXT Although the introduction of a new method is generally hailed as a boon to contraceptive prevalence, uptake of new methods can reduce the use of existing methods. It is important to examine changing patterns of contraceptive use and method mix after the introduction of new methods. METHODS Demographic and Health Survey data from 13 countries were used to analyze changes in method use and method mix after the introduction of the injectable in the early 1990s. Subgroup analyses were conducted among married women who reported wanting more children, but not in the next two years (spacers), and those who reported wanting no more children (limiters). RESULTS Modern method use and injectable use rose for each study country. Increases in modern method use exceeded those in injectable use in all but three countries. Injectable use rose among spacers, as well as among limiters of all ages, particularly those younger than 35. In general, the increase in injectable use was partially offset by declines in use of other methods, especially long-acting or permanent methods. CONCLUSION Family planning programs could face higher costs and women could experience more unintended pregnancies if limiters use injectables for long periods, rather than changing to longer acting and permanent methods, which provide greater contraceptive efficacy at lower cost, when they are sure they want no more children.