International Perspectives on Sexual and Reproductive Health最新文献

Context: School-based interventions that aim to modify sexual health knowledge, attitudes and behaviors have mixed and often unsustained effects on adolescent sexual health outcomes. However, observational evidence suggests that broader school-related factors, such as school climate and academic attainment, can influence outcomes.

Methods: Nine databases were searched in July 2017 for randomized and quasi-experimental evaluations of interventions addressing school-level environment or student-level educational assets, to examine whether such interventions can promote young people's sexual health. Searches were limited to studies published since 1990 but were not restricted by language. Studies were assessed for risk of bias and synthesized narratively and meta-analytically.

Results: Searches yielded 11 evaluations, published from 1999 to 2016, of interventions related to school-level environment or student-level educational assets. Because of inconsistent reporting, the risk of bias was not clear for most studies, and meta-analysis was possible for only one outcome. The meta-analysis of three randomized trials provided some evidence that school-environment interventions may delay sexual debut (pooled odds ratio, 0.5). Narrative synthesis of the remaining outcomes found mixed results, but suggests that interventions addressing school-level environment may delay sexual debut and that those addressing student-level educational assets may reduce risk of pregnancy and STDs.

Conclusions: Additional and more rigorous evidence is needed to assess the probability that interventions addressing school-related factors are effective and to provide better understanding of the mechanisms by which they may work to improve adolescent sexual health.

Context: Despite efforts to use facility surveys to measure the quality of family planning programs, routine, reliable measurement and monitoring of national-level quality has not been possible.

Methods: A new composite index to measure national-level quality, the National Quality Composite Index (NQCI), is proposed and used to compare program quality in 30 developing countries. Index scores represent the unweighted average of scores from indicators of three different dimensions of quality-structure, process and outcome. The structural indicator, the Method Availability Index, used data from the 2014 Family Planning Effort survey, while the process indicator (the Method Information Index) and outcome indicator (the Method Success Index) used data from the most recent Demographic Health Surveys conducted in the included countries. Correlations between these and other indicators were examined.

Results: The unweighted average NQCI score for the 30 countries was 60; scores ranged from 50 in Pakistan to 72 in Cambodia. The average scores for the three NQCI components were 52 for Method Availability (range, 40-73), 41 for Method Information (range, 13-71) and 86 for Method Success (range, 70-99). Scores for these components were not correlated with each other, suggesting that they measure distinct dimensions of program quality. Overall NQCI scores were correlated with existing measures of national-level quality, but not with total fertility rate and modern contraceptive prevalence rate.

Conclusions: The NQCI and its three components use data routinely collected through national surveys, and can be used to measure and monitor national-level quality of family planning programs.

Context: Surveys that use direct questions to ascertain women's history of induced abortion tend to underestimate abortion prevalence, especially in such contexts as Iran where the procedure is legally restricted and highly stigmatized. No previous study has compared two indirect techniques for estimating abortion prevalence.

Methods: A sample of 708 married women were recruited from one public hospital in Tehran between August and December 2013. Participants completed a survey, which included induced abortion estimation using the randomized response technique (RRT) and the unmatched count technique (UCT), as well as questions about demographic characteristics, trust in direct questions about abortion, and comprehensibility of and trust in RRT and UCT. Prevalence of induced abortion was calculated for each technique. Spearman correlation was used to evaluate whether comprehensibility of and trust in estimation methods were associated with women's age and education.

Results: The prevalence of induced abortion was estimated to be 14% using RRT and 12% using UCT; the estimates were not significantly different. Ninety-one percent of women reported that UCT was very easy to comprehend; the proportion for RRT was 78%. Sixty-three percent of women reported completely trusting in the confidentiality of UCT; the proportion for RRT was 50%. Age was inversely associated with comprehensibility for UCT (correlation coefficient, -0.13), and with trust for both RRT and UCT (-0.12 and -0.08, respectively); education was directly associated with trust for both methods (0.24 and 0.22).

Conclusions: Of the two indirect methods, UCT may be simpler and more dependable for the estimation of induced abortion prevalence in low-literacy, abortion-restricted settings.

Context: Although abortion is illegal in most of Mexico, it was decriminalized in Mexico City in 2007, creating an island of legal abortion in a sea of restricted access. The characteristics of women seeking abortions in Mexico City-notably their socioeconomic status and place of residence-have not been well documented.

Methods: Medical records from 22,732 women who sought abortions at one of four primary-level clinics in Mexico City in 2013-2015 were used to examine characteristics of women seeking legal abortion. Linear regression analyses were used to explore differences between women from Mexico City and those from elsewhere in Mexico, using education as a proxy for socioeconomic status. Because of geographic differences in population structure, women's education level was normalized in some models.

Results: Most abortion seekers came from Mexico City (66%) or its surrounding metropolitan area (22%), while the remainder came from bordering states (7%) or the rest of Mexico (5%). Abortion seekers from the rest of Mexico had, on average, 1.4 more years of education than did those from Mexico City. In regression models that normalized education levels, the difference in educational attainment between women from the rest of Mexico and those from Mexico City was 4.9 years (unadjusted model) and 3.2 years (adjusted model).

Conclusions: These findings, in conjunction with the literature on unsafe abortion in Mexico, suggest that women from outside Mexico City who have low levels of education may be less likely than their more educated peers to benefit from the safe abortion services provided in the city.

Context: Unsafe abortion is common in Kinshasa, which contributes to high rates of maternal morbidity and mortality. Little is known about the complications and treatment experienced by women seeking postabortion care at health facilities in the city.

Methods: Data from 867 women admitted to a sample of health facilities providing postabortion care in Kinshasa in 2016 were drawn from a Prospective Morbidity Survey. A measure of severity of postabortion complications was developed on the basis of information from these women and their primary care provider. Generalized ordered logistic regression analyses were used to examine associations between the characteristics of postabortion care patients and complication severity.

Results: Nearly three-fourths (72%) of postabortion care patients were classified as certainly having had an induced abortion, and another 16% as probably having had one. Sixteen percent of postabortion care patients experienced severe complications, 46% moderate complications and 33% mild complications; 5% had no evidence of complications. Severity of complications was associated with certain patient characteristics: For example, poor patients and those who had never been married had elevated odds of having experienced severe or moderate complications rather than mild or no complications (odds ratios, 1.8-1.9). Patients' complications were most commonly treated with such outdated methods as dilation and curettage and digital curettage (49% and 23%, respectively); only 11% of patients received medication for pain.

Conclusions: Policies and programs promoting contraceptive use and safe legal abortion are needed in Kinshasa to reduce women's recourse to unsafe abortion. Improved quality postabortion care provision is also needed, including World Health Organization-recommended methods.

Context: Health care providers' biases regarding the provision of contraceptives to adolescent and young adult women may restrict women's access to contraceptive methods.

Methods: Two mystery client visits were made to each of 52 private-sector health care facilities and individual providers in South West Nigeria in June 2016. In one visit, the mystery client portrayed an unmarried, nulliparous adolescent, and in the other, the client portrayed a married adult woman with two children. During subsequent in-depth interviews, providers were read vignettes describing hypothetical clients with these same profiles, and were asked how they would interact with each. Descriptive analyses of mystery client interactions were combined with thematic analyses of the interview data.

Results: In greater proportions of married-profile visits than of unmarried-profile visits, mystery clients reported that providers had asked about past contraceptive use and method preference; the opposite was true in regard to providers' using side effects to dissuade clients from practicing contraception. In in-depth interviews, providers expressed concerns about fertility loss among unmarried women who used hormonal contraceptives. Providers more commonly recommended condoms, emergency contraception and the pill for unmarried clients, and longer-acting methods for married clients. The restriction of methods was typically explained by providers of various backgrounds in terms of protecting younger, unmarried clients from damaging their fertility.

Conclusions: Provider bias in the provision of contraceptives to adolescent and young adult women in South West Nigeria may affect quality of care and method choice. Interventions to reduce provider bias should go beyond technical training to address the underlying sociocultural beliefs that lead providers to impose restrictions that are not based on evidence.

Context: Safer-conception counseling may help people living with HIV to reduce the risk of transmission to partners and children. However, such counseling is rarely offered or evaluated in low-income countries.

Methods: In 2014-2015, in-depth qualitative interviews were conducted at a Ugandan HIV clinic with 42 HIV-positive clients and 16 uninfected partners who had participated in a safer-conception counseling intervention for serodiscordant couples seeking to have a child. Participants attended up to six monthly counseling sessions in which they received instruction and ongoing support in using the safer-conception method they selected. Content analysis of interview transcripts was used to identify themes related to the benefits and challenges of safer-conception counseling.

Results: Almost two-thirds of participants felt that safer-conception counseling was an empowering experience that enabled them to make informed choices regarding childbearing, learn how to conceive safely and understand how to stay healthy while trying to conceive. Timed unprotected intercourse was the most frequently used safer-conception method. Seven couples had successful pregnancies, and no uninfected partners seroconverted. Participants' primary concerns and challenges regarding counseling and method use were issues with manual self-insemination, difficulty with engaging partners and fear of HIV infection.

Conclusions: Counseling can help HIV-infected individuals make informed choices about childbearing and safer-conception methods; however, a controlled clinical trial is needed to determine whether clients use such methods correctly and to assess rates of pregnancy and transmission. Policymakers need to consider including safer-conception counseling as part of routine HIV care.

Context: Short pregnancy intervals can contribute to maternal and child morbidity and mortality. No previous research has explored factors associated with short pregnancy intervals among young women in Uganda, where adolescent pregnancy and short birth intervals are common.

Methods: Data on 626 married or cohabiting women aged 15-22 with one or two previous pregnancies were drawn from the 2011 Uganda Demographic and Health Survey. Bivariate and multivariable logistic regression analyses were used to examine characteristics associated with rapid repeat pregnancy, defined in two ways: a pregnancy occurring within 24 months or 12 months of a prior pregnancy outcome.

Results: Among women, 74% and 37% had experienced a rapid repeat pregnancy within 24 months and 12 months, respectively. Rural women were more likely than urban women to have had a rapid repeat pregnancy within 24 months (odds ratio, 2.4). Women aged 15-17 and those 18 or older at first union were more likely than women younger than 15 to have had a rapid repeat pregnancy within 24 months (3.8 and 3.4); those whose partner had at least a secondary education had lower odds than others of the outcome (0.6). The odds of rapid repeat pregnancy increased with the number of months between marriage and first birth (1.05). Variables associated with rapid repeat pregnancy within 12 months included urban-rural residence, region, age at first union and marriage-to-birth interval.

Conclusions: Efforts to reduce rapid repeat pregnancy among young women in Uganda should focus on rural areas. Strategies to reach women during antenatal care and the postpartum period after their first birth should be prioritized.

The objective of this article is to review key components of LARC uptake in Sub-Saharan Africa with the aim of guiding policies and programs. We assess trends in access to the IUD and implant, including method knowledge and availability at facilities; examine trends in use, source of supply, discontinuation and characteristics of users; and discuss the prospects for expanding method choice by increasing the availability of LARCs in national programs and the policy implications of our results.