C-CHANGE
C-Channel:
Issue 23 | SEPTEMBER 2010
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Women and contraceptive choice

C-Channel 23 highlights women and contraceptive choice.

Of Interest…

ACCESS-FP, funded by USAID, issued the publication, "Postpartum Fertility and Contraception: An Analysis of Findings from 17 Countries." It uses Demographic and Health Survey (DHS) data and aims to understand factors that may affect unmet family planning needs.

Download report.

Six articles describe women's contraceptive choice and use, two describe family planning and post-abortion care, and a final two examine adolescents and contraception. Research for these articles was conducted in Brazil, Iran, Kenya, Nigeria, South Africa, Sudan, and Zimbabwe. One large study was conducted in 40 developing countries.

C-Change trained 3,000 relais (community health workers) in DRC's three eastern provinces—Kasai Oriental, Katanga, and Kasai Occidental—on use of the Family Planning Conversation Tool. Developed by C‑Change/DRC partners, CARE and AED, the Tool assists relais as they talk to groups of men and women about family planning. Issues include spacing of pregnancies for the health of the mother and her children, visiting the health clinic for antenatal care, and adopting the use of modern contraceptives, etc. For more information, visit the C-Change website.

In this issue

Women - Contraceptive Choice and Use

1. HIV-positive women's contraceptive use - South Africa

2. Contraceptive discontinuation and non-use - Brazil
ONLINE FULL TEXT

3. Women, diaphragms, and lubricant gel - Southern Africa

4. Women's preference for withdrawal - Iran
ONLINE FULL TEXT

5. Contraceptive choices of rural women - Nigeria
ONLINE FULL TEXT

6. Postpartum sexual health in urban slums - Kenya

Family Planning and Post-Abortion Care

7. Urban unsafe abortion and abortion care - Sudan

8. Post-abortion contraceptive choice - Brazil
ONLINE FULL TEXT

Adolescents and Contraception

9. Undergraduates and contraception - Nigeria

10. Adolescents vs. adult women - contraceptive use and discontinuation


Women - Contraceptive Choice and Use

1. A qualitative assessment of decisions affecting contraceptive utilization and fertility intentions among HIV-positive women in Soweto, South Africa

Authors: Laher F; Todd CS; Stibich MA; Phofa R; Behane X; Mohapi L; Gray G
Institution: Perinatal HIV Research Unit, University of the Witwatersrand, Diepkloof, Johannesburg, Soweto, South Africa
Source: AIDS and Behavior, Jun 2009; 13(S1): 47-54. [Epub before print]

ABSTRACT

The HIV epidemic in sub-Saharan Africa disproportionately affects women of reproductive age. The increasing provision of Highly Active Anti-Retroviral Therapy (HAART) with improved prognosis and maternal-fetal outcomes calls for an understanding of fertility planning for HIV-positive women. We describe the effect of HIV and HAART on pregnancy desires and contraceptive use among HIV-positive women in Soweto, South Africa. Focus group discussions and in-depth interviews were conducted with 42 HIV-positive women of reproductive age. Analysis was performed using ATLAS-ti (ATLAS-ti Center, Berlin). Emergent themes were impact of HIV diagnosis on pregnancy intentions; factors affecting contraceptive uptake including real and normative side effects, body image, and perceived vaginal wetness; and the mitigating influence of partnership on both pregnancy intentions and contraceptive use. Routine counseling about pregnancy desires and contraception should be offered to HIV-positive women.

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2. Contraceptive discontinuation and non-use in Santarém, Brazilian Amazon

Authors: D'Antona Ade O 1,2; Chelekis JA 1; D'Antona MF 1; Siqueira AD 1
Institutions: 1 Anthropological Center for Research and Training on Global Environmental Change, Indiana University, IN; 2 Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Campinas, Brasil
Source: Cadernos de Saúde Publica, Sep 2009; 25(9): 2021-32. [Open Access]

ABSTRACT

In this paper we discuss the causes of non-adherence to reversible contraceptives, especially hormonal methods, among women in rural Santarém in the Brazilian Amazon. The analysis is based on questionnaires with 398 women and visits to health centers. We consider the motives reported by women who: never used contraception; used some method in the past; and who at the time of the survey were using a different method from the ones they used in the past. The results indicate a rejection of hormonal contraception and a preference for female sterilization, an option possibly influenced by the characteristics of health services in the region. The side effects of hormonal contraceptive use reported by part of the interviewees contribute to a generalized fear of the side effects even among women who have never used such methods. To improve women's health services in the Amazon, we recommend further studies of the relationship between reported side effects and available services and prescriptions, as well as an analysis of women's discourse and perceptions.

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3. Diaphragm and lubricant gel acceptance, skills and patterns of use among women in an effectiveness trial in Southern Africa

Authors: Montgomery ET 1,2; Blanchard K 3; Cheng H 1; Chipato T 4; de Bruyn G 5; Ramjee G 6; Padian N 1; van der Straten A 1,7
Institutions: 1 Women's Global Health Imperative, RTI International, San Francisco Project Office, San Francisco, CA; 2 London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; 3 Ibis Reproductive Health, Cambridge, MA and Johannesburg, South Africa; 4 University of Zimbabwe-University of California San Francisco Collaborative Research Programme, Harare, Zimbabwe; 5 Perinatal HIV Research Unit, Johannesburg, South Africa; 6 Medical Research Council, Kwazulu-Natal, South Africa; 7 Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA
Source: The European Journal of Contraception and Reproductive Health Care, Dec 2009; 14(6): 410-9. [PubMed]

ABSTRACT

OBJECTIVES: We examined diaphragm and gel-related skills, patterns of use, and problems, among women who participated in the MIRA study, a multisite phase III diaphragm trial in Zimbabwe and South Africa.

METHODS: We evaluated whether baseline characteristics were associated with the ability to correctly insert/remove the diaphragm prior to randomisation by means of multivariate logistic regression modeling. Employing face-to-face interviews with intervention arm participants, patterns of use and comfort using the products were measured at Month 3 and Exit, and reported problems with the products were assessed quarterly.

RESULTS: At baseline, 72.5% of women correctly inserted/removed the diaphragm within one attempt, and this skill was most strongly associated with the Johannesburg study site. At exit, over 90% of intervention women were very comfortable inserting, wearing, cleaning and removing the diaphragm; however, 31.8% reported usual removal of the diaphragm before the prescribed six hours after sex. During the 12-24 month follow-up period there were only 133 (<1%) reported problems with the diaphragm and gel over 14,544 follow-up visits.

CONCLUSIONS: Diaphragm skills were easily acquired and few problems were reported during the course of the trial. Reviving the diaphragm as a contraceptive option or as a reusable microbicide delivery mechanism seems feasible in these settings.

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4. Why do Iranian married women use withdrawal instead of oral contraceptives? A qualitative study from Iran

Authors: Rahnama P 1; Hidarnia A 1; Shokravi FA 1; Kazemnejad A 2; Oakley D 3; Montazeri A 4
Institutions: 1 Department of Health Education, Tarbiat Modares University, Tehran, Iran; 2 Department of Biostatistics, Tarbiat Modares University, Tehran, Iran; 3 School of Nursing, University of Michigan, Ann Arbor, MI; 4 Department of Mental Health, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran
Source: BMC Public Health, 28 May 2010; 10:289. [Open Access]

ABSTRACT

BACKGROUND: Withdrawal as a method of birth control is still used in Iran. The aim of this study was to explore married women's perspectives and attitudes on withdrawal use instead of oral contraceptive (OC) in Tehran, Iran.

METHODS: This was a qualitative study. Participants were 50 married women, not currently pregnant, not desiring pregnancy and who had been using withdrawal for contraception. Face-to face interviews were conducted to collect data. Content analysis was performed to analyze the data.

RESULTS: Four major themes were extracted from the interviews: advantages, disadvantages, barriers for OC use, and husband-related factors. Advantages of withdrawal use were identified as: easy to use, convenient, ease of access, natural. Even those participants who had experienced unwanted pregnancy while using withdrawal, relied on withdrawal as their contraceptive method. Disadvantages of OC included concerns about side effects. Barriers related to use of OC included the need for medical advice, vaginal examination and daily use. Husband-related factors included: the husband wanted to be the primary decision maker on the number of children and that he preferred withdrawal.

CONCLUSION: Health providers should address misunderstandings that exist about OC and highlight the non-contraceptive health benefits of OC to balance the information provided for women. We suggest that not only women but also their spouses be advised in family planning programs.

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5. Contraceptive choices of women in rural Southeastern Nigeria

Authors: Chigbu B; Onwere S; Aluka C; Kamanu C; Okoro O; Feyi-Waboso P
Institution:Department of Obstetrics and Gynaecology, Abia State University Teaching Hospital Aba, Nigeria
Source: Nigerian Journal of Clinical Practice, Jun 2010; 13(2): 195-9.

ABSTRACT

OBJECTIVE: To evaluate the contraceptive choices and usage of women in rural Aba, Southeastern Nigeria, and identify factors influencing their choice and usage of modern contraceptive methods.

METHODS: The records of new and old acceptors of family planning methods between 1 November 2005 and 31 October 2007 at the reproductive health clinic of a primary health care center in Osisioma Ngwa local government area in the suburb ofAba, were reviewed and analyzed. Qualitative data was collected by in-depth interviews (IDIs) of 88 out of 188 clients whose records were analyzed.

RESULTS: Majority of the clients (71.8%) accepted injectable hormonal contraceptives followed by the intrauterine contraceptive devices (IUDs) (14.4%). Sub-dermal contraceptive implants were accepted by 6.9% of the women and female sterilization by 3.2%. The oral contraceptive pills and the male condom were the least accepted by the clients. Only 2.1% of the contraceptive acceptors were adolescents. The modal age of the acceptors was 30 years and the average age 33.4 years while the age range was 18-51 years. The average parity was 4.7 while the modal parity was 5. The indication for contraception was child spacing in 30% of the clients and permanent limitation of the family size in 70% of the clients. Attitude of the women to the various methods of contraception was an important factor influencing contraceptive choices of the women interviewed.

CONCLUSION: The study has shown that the most commonly used contraceptive method in rural Southeastern Nigeria is the injectable hormonal contraceptives. Strategies to increase contraceptive use in rural Nigeria must include improving delivery of correct and adequate information about the available contraceptive methods.

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6. Menstrual pattern, sexual behaviors, and contraceptive use among postpartum women in Nairobi urban slums

Authors: Ndugwa RP 1; Cleland J 1; Madise NJ 4; Fotso JC 2; Zulu EM 3
Institutions: 1 London School of Hygiene and Tropical Medicine, London, UK; 2 African Population and Health Research Center, Nairobi, Kenya; 3 African Institute for Development Policy Research and Dialogue, Nairobi, Kenya; 4 University of Southampton, Southampton, UK
Source: Journal of Urban Health, 7 May 2010; doi: 10.1007/ss11524-010-9452-6. [Epub ahead of print; PubMed]

ABSTRACT

Postpartum months provide a challenging period for poor women. This study examined patterns of menstrual resumption, sexual behaviors and contraceptive use among urban poor postpartum women. Women were eligible for this study if they had a birth after the period September 2006 and were residents of two Nairobi slums of Korogocho and Viwandani. The two communities are under continuous demographic surveillance. A monthly calendar type questionnaire was administered retrospectively to cover the period since birth to the interview date and data on sexual behavior, menstrual resumption, breastfeeding patterns, and contraception were collected. The results show that sexual resumption occurs earlier than menses and postpartum contraceptive use. Out of all postpartum months where women were exposed to the risk of another pregnancy, about 28% were months where no contraceptive method was used. Menstrual resumption acts as a trigger for initiating contraceptive use with a peak of contraceptive initiation occurring shortly after the first month when menses are reported. There was no variation in contraceptive method choice between women who initiate use before and after menstrual resumption. Overall, poor postpartum women in marginalized areas such as slums experience an appreciable risk of unintended pregnancy. Postnatal visits and other subsequent health system contacts provide opportunities for reaching postpartum women with a need for family planning services.

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Family Planning and Post-Abortion Care

7. Unsafe abortion and abortion care in Khartoum, Sudan

Authors: Kinaro J a; Ali TE b,c; Schlangen R d; Mack J e
Institutions: a Senior Program Officer, Planned Parenthood Federation of America (PPFA), Africa Region, Nairobi, Kenya; b Obstetrics and Gynaecology, Academy of Medical Sciences & Technology, Khartoum, Sudan; c Safe International, Khartoum, Sudan; d Senior Research and Evaluation Manager, International Division, PPFA, New York, NY; e Program Associate, International Division, PPFA, New York, NY
Source: Reproductive Health Matters, Nov 2009; 17(34): 71-7.

ABSTRACT

Unsafe abortion in Sudan results in significant morbidity and mortality. This study of treatment for complications of unsafe abortion in five hospitals in Khartoum, Sudan, included a review of hospital records and a survey of 726 patients seeking abortion-related care from 27 October 2007 to 31 January 2008, an interview of a provider of post-abortion care and focus group discussions with community leaders. Findings demonstrate enormous unmet need for safe abortion services. Abortion is legally restricted in Sudan to circumstances where the woman's life is at risk or in cases of rape. Post-abortion care is not easily accessible. In a country struggling with poverty, internal displacement, rural dwelling, and a dearth of trained doctors, mid-level providers are not allowed to provide post-abortion care or prescribe contraception. The vast majority of the 726 abortion patients in the five hospitals were treated with dilatation and curettage (D&C), and only 12.3% were discharged with a contraceptive method. Some women waited long hours before treatment was provided; 14.5% of them had to wait for 5-8 hours and 7.3% for 9-12 hours. Mid-level providers should be trained in safe abortion care and post-abortion care to make these services accessible to a wider community in Sudan. Guidelines should be developed on quality of care and should mandate the use of manual vacuum aspiration or misoprostol for medical abortion instead of D&C.

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8. Choices on contraceptive methods in post-abortion family planning clinic in the northeast Brazil

Authors: Ferreira AL; Souza AI; Lima RA; Braga C
Institution: Instituto de Medicina Integral Prof Fernando Figueira (IMIP) - Research Department - Recife, Brazil
Source: Reproductive Health, 10 May 2010; 7:5. [Open Access]

 

ABSTRACT

BACKGROUND: In Brazil, a Ministry of Health report revealed women who underwent an abortion were predominantly in the use of contraceptive methods, but mentioned inconsistent or erroneously contraceptive use. Promoting the use of contraceptive methods to prevent unwanted pregnancies is one of the most effective strategies to reduce abortion rates and maternal morbidity and mortality. Therefore, providing post-abortion family planning services that include structured contraceptive counseling with free and easy access to contraceptive methods can be suitable. So the objective of this study is to determine the acceptance and selection of contraceptive methods followed by a post-abortion family planning counseling.

METHODS: A cross-sectional study was carried out from July to October 2008, enrolling 150 low income women to receive post-abortion care at a family planning clinic in a public hospital located in Recife, Brazil. The subjects were invited to take part in the study before receiving hospital leave from five different public maternities. An appointment was made for them at a family planning clinic at IMIP from the 8th to the 15th day after they had undergone an abortion. Every woman received information on contraceptive methods, side effects and fertility. Counseling was individualized and addressed them about feelings, expectations and motivations regarding contraception as well as pregnancy intention.

RESULTS: Of all women enrolled in this study, 97.4% accepted at least one contraceptive method. Most of them (73.4%) had no previous abortion history. Of the 40 women who had undergone a previous abortion, 47.5% reported undergoing unsafe abortion. Slightly more than half of the pregnancies (52%) were unwanted. All women had knowledge of the use of condoms, oral contraceptives and injectables. The most chosen method was injectables, followed by oral contraceptives and condoms. Only one woman chose an intrauterine device.

CONCLUSION: The acceptance rate of post-abortion contraceptive methods was greater and the most chosen method was the best-known one. Implementing a specialized family planning post abortion service may promote an acceptance, regardless of the chosen method. Most important is that they do receive contraception if they do not wish for an immediate pregnancy.

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Adolescents and Contraception

9. Contraceptive knowledge and practice: a survey of under graduates in Ibadan, Nigeria

Authors: Adeyinka DA; Oladimeji O; Adeyinka EF; Adekanbi IT; Falope Y; Aimakhu C
Institution: Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria
Source: International Journal of Adolescent Medicine and Health, Jul-Sep 2009; 21(3): 405-11. [PubMed]

ABSTRACT

Despite the mounting reproductive health problems among adolescents in Nigeria, very little has been done at governmental level to address the problem, hence presenting a major health concern and a leading cause of morbidity and mortality. OBJECTIVE: To determine the knowledge, attitude of the undergraduates to contraception and their practice of the various contraceptive options. METHODS: A descriptive cross-sectional study was done among the undergraduates of the Polytechnic of Ibadan and University of Ibadan, Nigeria. Interviewer-administered questionnaires were given to 600 consenting undergraduates. The data were analyzed using SPSS version 11 software. Chi2 and Fisher exact tests were used for categorical variables as appropriate. RESULTS: A large percent (65.1%) of the undergraduates were sexually experienced. Approximately, 90.2% of the respondents who had sex did so before the age of 19 years, 31.8% had more than one sexual partner, and 21.8% had clandestine abortions. All respondents were quite knowledgeable about HIV/AIDS but few (30.2%) of the sexually active took precautions to prevent HIV transmission. The majority (65.4%) were not knowledgeable about contraception, and 10.5% heard about contraception from parents. About 52.3% of the latter cited pharmacy shops as their source of contraceptives. CONCLUSION: The attitudes of the students were below expectations. Specially designated centers for the provision of appropriate contraceptive services to students by trained personnel are needed in the institutions to tackle their reproductive health problems.

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10. Patterns and trends in adolescents' contraceptive use and discontinuation in developing countries and comparisons with adult women

Authors: Blanc AK 1; Tsui AO 2; Croft TN 4; Trevitt JL 3
Institutions: 1 Maternal Health Task Force, EngenderHealth, New York, NY; 2 Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 4 Blancroft Research International, Columbia, MD
Source: International Perspectives on Sexual and Reproductive Health, Jun 2009; 35(2): 63-71.

ABSTRACT

CONTEXT: The reproductive choices made by young women and men have an enormous impact on their health, schooling, employment prospects and overall transition to adulthood. As the largest cohort of young people in history enter their childbearing years, their reproductive behavior will determine the growth and size of the world's population for decades to come.

METHODS: Demographic and Health Survey data from more than 40 countries were used to examine the proportions of 15-19-year-old women who are currently married or are unmarried but sexually active; their rates of contraceptive adoption, current use, discontinuation, method switching and contraceptive failure; trends in these indicators; and comparisons with older women.

RESULTS: In many countries, the proportion of adolescent women using contraceptives increased substantially over the last two decades; prevalence among adolescents increased faster than among older women. Greater proportions of adolescents than of older women discontinued using a contraceptive method within a year or experienced contraceptive failure.

CONCLUSIONS: Adolescent contraceptive use is growing, and compared with adult use, is characterized by shorter periods of consistent use with more contraceptive failure and more stopping for other reasons. Use through the reproductive years is likely to grow, fueled further by growth in the numbers of young people. An expanded demand for contraceptive supplies, services and information can be expected to challenge the preparedness, capacity and resources of existing family planning programs and providers.

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