International Perspectives on Sexual and Reproductive Health最新文献

Context: Evidence shows that laws that restrict abortion do not eliminate its practice, but instead result in women having clandestine abortions, which are likely to be unsafe. It is important to periodically assess changes in the legal status of abortion around the world.

Methods: The criteria for legal abortion as of 2019 for 199 countries and territories were used to distribute them along a continuum of six mutually exclusive categories, from prohibited to permitted without restriction as to reason. The three most common additional legal grounds that fall outside of this continuum-rape, incest and fetal anomaly-were also quantified. Patterns by region and per capita gross national income were examined. Changes resulting from law reform and judicial decisions since 2008 were assessed, as were changes in policies and guidelines that affect access.

Results: Legality correlated positively with income: The proportions of countries in the two most-liberal categories rose uniformly with gross national income. From 2008 to 2019,27 countries expanded the number of legal grounds for abortion; of those, 21 advanced to another legality category, and six added at least one of the most common additional legal grounds. Reform resulted from a range of strategies, generally involving multiple stakeholders and calls for compliance with international human rights norms.

Conclusions: The global trend toward liberalization continued over the past decade; however, even greater progress is needed to guarantee all women's right to legal abortion and to ensure adequate access to safe services in all countries.

Following the World Health Organization's (WHO) definition of self-care, abortion self-care is the ability of pregnant individuals to manage their unwanted pregnancies with or without the support of health care providers-particularly, in the early weeks of pregnancy (up to 12 weeks' gestation). The advent of medication abortion (MA) has made this possible, as early self-managed MA at home is a safe, acceptable and cost-effective method of pregnancy termination. The drugs currently available for MA are mifepristone and misoprostol, as well as the two packaged together (also known as the combipack), which is more efficacious than misoprostol alone in evacuating the uterus and is considered the first-line medication for MA. Regardless of the legality of abortion where they live, women worldwide are using these medications to self-manage pregnancy termination inside or outside clinical settings-in conjunction with telemedicine services, peer-led support groups, hotlines and online information sources-which has contributed significantly to reducing maternal mortality and morbidity from unsafe procedures.

Context: Hygienic use of absorbent products during menstruation is a challenge for young women in India, especially among the underprivileged, who lack knowledge and access to resources. Reuse of menstrual absorbents can be unhygienic and result in adverse health and other outcomes.

Methods: Data from the 2015-2016 National Family Health Survey-4 for 233,606 menstruating women aged 15-24 were used to examine levels and correlates of exclusive use of disposable absorbents during menstruation. Bivariate and logistic regression analyses were conducted to identify disparities in exclusive use by such characteristics as caste, mass media exposure and interaction with health workers.

Results: Exclusive use of disposable absorbents was low among young women overall (37%), and varied substantially by caste and other characteristics. Compared with women from general castes, those from scheduled castes, scheduled tribes and other backward classes had reduced odds of exclusive disposable absorbent use (odds ratios, 0.8-0.9). Disposable absorbent use was negatively associated with lower levels of education and household wealth, and rural residence. Compared with women who reported daily media exposure, those exposed less frequently had reduced odds of disposable absorbent use (0.7-0.9). Among those who recently met with a health worker, odds of use were lower if menstrual hygiene had not been discussed (0.9).

Conclusions: Promoting awareness of proper menstrual hygiene-through education, media campaigns and discussion with reproductive health workers-and targeted interventions to disseminate and subsidize the purchase of disposable sanitary napkins should be pursued to address health disparities.

Context: Improving women's empowerment is pivotal to public health and development programs; however, inconsistent definitions and lack of cross-cultural measures compromise monitoring efforts.

Methods: Data collected in 2017-2018 in Ethiopia, Uganda and two sites in Nigeria were used to develop a cross-cultural index of women's and girls' empowerment in sexual and reproductive health (WGE-SRH). Item development was grounded in qualitative interviews, and informed by a conceptual framework that included domains of existence of choice and exercise of choice related to sex, contraceptive use and pregnancy. Items were pilot tested among 1,229 women aged 15-49 across sites. Psychometric properties were explored to identify crosssite constructs, and logistic regression was used to assess the construct validity of each dimension.

Results: Analyses identified subscales for sexual existence of choice (Cronbach's alphas, 0.71-0.79) and contraceptive existence of choice (0.56-0.78). A pregnancy existence of choice subscale emerged for only two sites (0.61-0.80). Internal reliability of the exercise of choice subscales varied. Construct validity analyses found that for some sites, high scores on the sexual and contraceptive existence of choice subscales were associated with elevated odds of volitional sex and contraceptive use, respectively. Combining the existence of choice and exercise of choice summary scores for sex strengthened associations with volitional sex.

Conclusions: The cross-cultural WGE-SRH index can be used to assess existence of choice related to contraception and volitional sex. Further work is needed to improve measures of SRH exercise of choice, and investigate the index's multidimensionality and associations with SRH outcomes.

Context: In Indonesia, maternal mortality is high and abortion is restricted. Reliable information on induced abortion is needed; however, the difficulty of measuring abortion in settings where it is legally restricted and highly stigmatized calls for innovation in approaches to measuring abortion incidence.

Methods: The data were from three original surveys conducted in Java among health facilities, knowledgeable informants and women aged 15-49, fielded in April 2018-January 2019. Two methods were used to estimate the one-year induced abortion incidence rate in Java: the standard Abortion Incidence Complications Method (AICM) and a modified AICM. Each method was evaluated on the basis of data quality, and what is known about sexual and reproductive health indicators related to abortion rates, to determine which performed best in measuring abortion incidence in Java.

Results: Estimates of complications resulting from induced abortion from knowledgeable informants and the women differed substantially. The modified AICM produced an estimate of 42.5 abortions per 1,000 women aged 15-49, while the standard AICM estimate was lower (25.8 per 1,000). A comparison of the distribution of abortion methods used revealed that knowledgeable informants believed abortion was less safe than indicated by women's reports of their own experiences. Therefore, the standard AICM likely underestimates abortion.

Conclusions: The modified AICM performed better than the standard AICM and indicates that abortion is common in Java. Increased access to contraceptives and high-quality postabortion care is needed. Future research should investigate the safety of abortion, especially with respect to self-managed abortion.

Context: Induced abortion is legally restricted and highly stigmatized in Indonesia, and is thus extremely difficult to measure. Indirect methods leveraging women's social networks, such as the Confidante Method, have shown promise in estimating hidden behaviors, including abortion, in similar settings.

Methods: A community-based survey was conducted among 8,696 women aged 15-49 in Java, Indonesia, in November 2018-January 2019. Data were collected via in-person interviews with respondents about their own abortions and those of up to three of their closest confidantes. One-year induced abortion incidence rates per 1,000 women were estimated using a direct-report approach and the Confidante Method.

Results: The direct-report abortion rate was 3.4 per 1,000 women in 2018, compared with the Confidante Method rate of 11.3 per 1,000. Among the confidantes of women who reported an abortion in the past five years, the abortion rate was 42.0 per 1,000. Half of the women reported that they had no confidantes with whom they shared private information. Among women reporting an abortion and at least one confidante, 58% had disclosed their abortion to their confidante, indicating that substantial transmission bias was present.

Conclusions: The Confidante Method relies on several assumptions that did not hold in this study. Although the method performed better than the direct-report approach, it underestimated the incidence of abortion in Java. More research is needed to understand how abortion-related information is shared within social networks and to assess the appropriateness of applying the Confidante Method to estimate abortion in a given context.

Context: Male contraceptive options are limited; however, product development efforts tend to focus on female methods. Research on attitudes toward methods for men-particularly in regions of low contraceptive prevalence, such as Sub-Saharan Africa-could inform the development of new male methods.

Methods: Qualitative data were taken from focus group discussions with 80 men aged 23-67 and 398 women aged 15-50 conducted in Burkina Faso and Uganda in 2016. Transcripts were analyzed thematically to explore support among men and women for male contraceptive methods, and to extract suggestions about ideal method characteristics.

Results: Male and female participants in both countries expressed support for new male contraceptive options; more positive attitudes were expressed in Uganda than in Burkina Faso. Participants of both sexes recognized that male methods could reduce the family planning burden on women and offer men greater control over their fertility; however, some had concerns about side effects and thought that men would not use contraceptives. Relationship characteristics, such as polygamous unions, were cited as possible challenges. In both countries, various delivery methods (e.g., creams or jellies, injections and implants) and durations (from short-acting to permanent) were proposed.

Conclusions: The acceptability of new male methods among most participants in the two countries indicates a potential demand for male contraceptives. Options should include a variety of method characteristics to maximize choice, engage men, and support men and women's contraceptive needs.

Context: Extreme weather events cause large-scale population displacement in Bangladesh. It is important to know how household displacement due to such events might affect women's antenatal care (ANC) service utilization.

Methods: In 2017, a cross-sectional household survey was conducted in 25 rural villages in either displacement prone or non-displacement prone areas of Bangladesh. Data were collected from 611 respondents (a woman or her husband) who reported having had a live birth in the past three years; of those, 289 had experienced household displacement due to an extreme weather event. Logistic regression analyses were conducted to examine the relationship between experience of household displacement and women's ANC service utilization during their last pregnancy resulting in a live birth.

Results: Eighty-three percent of women had received at least one ANC visit during their last pregnancy resulting in a live birth; of those, 31% received at least four visits with a trained provider. Women from households that had been displaced three or more times were less likely than those from nondisplaced households to have received an ANC visit and at least four visits with a trained provider (odds ratios, 0.3 and 0.4, respectively). Receiving at least four visits with a trained provider was also associated with having previous children (0.3-0.4), age at pregnancy (2.5-3.9), husband's occupation (2.2 for "other") and joint parental decision-making about ANC visits (1.8).

Conclusions: Strengthening family planning services and extending eligibility for Bangladesh's Maternity Allowance benefits in the areas prone to floods and riverbank erosion are recommended to improve ANC service utilization.

Context: Having one's first sexual intercourse be a positive and satisfying experience may be critical to healthy sexual development. Few studies, however, have examined adolescents' sexual satisfaction and the factors associated with enhancing or diminishing it, especially in Mexico.

Methods: Data from 4,504 heterosexual, sexually experienced 15-20-year-olds living in three Mexican states (Morelos, Jalisco and Puebla) were taken from the 2014 Survey on Dating, Empowerment, and Sexual and Reproductive Health in Adolescent High School Students. Multinomial logistic regression was used to examine factors associated with satisfaction and dissatisfaction with one's first experience of sexual intercourse, separately by gender.

Results: Most adolescents reported feeling generally satisfied with their first sexual intercourse (51% very satisfied and 40% satisfied); the proportion feeling very satisfied was significantly higher among young men than among young women (58% vs. 42%). Among both young men and women, feeling very satisfied (rather than satisfied) with first sex was positively associated with greater approval of adolescent sex (relative risk ratios, 1.06 each), as well as with higher self-esteem (1.04 and 1.03, respectively). Other variables positively associated with feeling very satisfied included having had first sex with a boyfriend or girlfriend, having had first sex less than three months prior to the survey, high socioeconomic status (for males only) and older age (for females only).

Conclusions: Self-esteem and having a positive view of adolescent sexuality may play an important role in the experience of satisfying first sex among Mexican adolescents. These should be pivotal elements of educational programs aimed at helping adolescents develop a positive sexuality and feel entitled to and in control of their sexual lives.

Context: Despite the extensive literature on women's perceptions about contraceptive methods, distinctions between specific methods have rarely been investigated, men have often been excluded and comparable data for contraceptive users and nonusers have typically not been collected. The lack of such information may limit family planning programs' effectiveness.

Methods: Cross-sectional survey data from 1,162 women and 621 men were used to examine perceived barriers to and facilitators of use of contraceptive methods (the pill, injectable, subdermal implant, IUD and male condoms). Conditional logit regression analysis was used to examine associations between 13 method-specific perceptions and respondents' preference to use the male condom, injectable or implant among a subsample of 603 women and 295 men.

Results: Men's and women's perceptions differed the most with regard to side effects, sexual pleasure and partner support. The likelihood that a woman preferred to use a method was positively associated with her perception that it does not have side effects, has a desired influence on menstruation, has no impact on conceiving a future pregnancy, is easy to use covertly and was recommended by a friend (odds ratios, 1.3-1.7). The likelihood that a man preferred a method was positively associated with his perception that it has a desired influence on his partner's menstruation (1.7) and that his partner is very supportive of its use (2.1).

Conclusions: Family planning programs and health care providers should engage with both women and men to counteract misperceptions or negative beliefs about contraceptive methods, and should work to provide accurate information to couples.