International Perspectives on Sexual and Reproductive Health最新文献

Context: Intimate partner violence (IPV) is associated with negative physical and mental health outcomes. Antenatal care can act as a link to IPV services, but experiencing IPV may be associated with reduced uptake of antenatal care, an issue that has received little attention from researchers.

Methods: A scoping review was conducted to synthesize quantitative research on IPV and uptake of antenatal care in low-resource settings. Keyword searches of PubMed and other databases and snowball searches of reference lists were conducted to identify articles published in 2005-2015 that measured one or more types of IPV (physical, sexual or emotional) or controlling behavior and assessed the relationship of such abuse with use of antenatal care. For each identified article, key characteristics and findings were abstracted, and study quality was assessed.

Results: Sixteen articles, representing 10 low- and middle-income countries, met the inclusion criteria. Most studies were of medium-to-high quality but low rigor, reflecting the abundance of cross-sectional studies in the literature. In all 16 studies, IPV was negatively associated with initiation of antenatal care, number of visits or use of a skilled provider. Analyses revealed reduced odds of antenatal care use among women who had experienced IPV (odds ratios, 0.5-0.8) and elevated odds of antenatal care use among women who had not experienced IPV or of nonuse among women who had experienced IPV (1.2-4.1).

Conclusion: Women in low-resource settings who experience IPV have a reduced likelihood of obtaining optimal antenatal care and may benefit from interventions to mitigate barriers to care.

Context: In 2006, the Colombian Constitutional Court issued a decision largely decriminalizing abortion; however, illegal abortion persists. Understanding the barriers that cause women to resort to unsafe, illegal abortions could help improve access to legal services.

Methods: In-depth interviews were conducted in 2014 with 17 women aged 18 or older who had had legal abortions in the past year in Bogotá, Colombia, to identify barriers to abortion access and elucidate the ways in which these barriers affect women's decision making regarding abortion. Interview transcripts were coded and analyzed using standard techniques to find patterns, parallels and differences; a phenomenological approach guided the thematic analysis.

Results: Barriers related to knowledge and information, along with logistic, emotional, financial, cultural and religious barriers culminated in delays in obtaining comprehensive abortion services. Religion influenced social stigma, which manifested most powerfully in the obstructive behavior of health care providers and health insurance companies. Lack of understanding of current laws on abortion and conscientious objection was evident on the part of patients, health care providers and insurers.

Conclusion: Dissemination of accurate information regarding the availability of clinical and legal abortion is needed. Better training may help physicians, nurses and insurance company personnel understand their roles and legal responsibilities in abortion care and reduce delays in women's access to services.

Context: Use of maternal health care can reduce maternal morbidity and mortality in countries like Bangladesh, where rates of these outcomes are high. Community characteristics are associated with use of maternal care services, but it is unclear whether deviation from community norms is associated with service use.

Methods: Data from the 2014 Bangladesh Demographic and Health Survey on 4,106 ever-married women aged 15-49 were used to examine relationships between women's deviation from their communities on socioeconomic, fertility and other characteristics and use of maternal health care (antenatal care, delivery care, postpartum care and a composite measure). Characteristics were examined at the individual and community levels and as deviance variables that indicated whether respondents differed from local norms in a positive way (e.g., being employed when others were not) or a negative way (being unemployed when others had jobs). Associations were identified using logistic regression.

Results: Sixty-three percent of women had had postpartum care; smaller proportions had had delivery care (40%), antenatal care (27%) or all three types (17%). Several deviance variables were associated with service use. Negative deviance on women's employment was associated with antenatal care (odds ratio, 1.3); positive deviance on violence justification, exposure to family planning messages and husband's employment was associated with delivery care (1.3-4.8); positive deviance on husband's employment was associated with not receiving postpartum care (0.7); and negative deviance on women's employment and positive deviance on age at marriage were associated with receipt of all three services (1.4-1.7).

Conclusion: Understanding associations between deviation from community norms and receipt of maternal health care may provide deeper understanding of variation within communities regarding whether women use services.

Context: In Uganda, an estimated one in four adolescent women have begun childbearing. Many adolescent pregnancies are unintended because of substantial barriers to contraceptive access. The injectable contraceptive is the most commonly used method in Uganda, and a new subcutaneous version offers the possibility of reducing access barriers by offering a self-injection option. However, more information about adolescent attitudes toward and interest in self-injection is needed.

Methods: In 2015, in-depth interviews were conducted with a purposive sample of 46 adolescent women aged 15-19 from rural and urban areas of Gulu District. Respondents were asked about their demographic characteristics, experience with contraceptives and opinions about injectable contraception, then introduced to subcutaneous depot medroxyprogesterone acetate (DMPA-SC) and trained in how to give an injection using a model. They were then asked their opinion about contraceptive self-injection. The interviews were transcribed and analyzed qualitatively to identify key themes.

Results: Although the injectable was generally viewed favorably, some adolescents expressed reservations about the suitability of injectable contraception for adolescents. The most common concern was fear of infertility. The majority felt self-injection would be an appealing option to adolescents because of the time and money saved and the discreet nature of injecting at home. Barriers to self-injection included fear of needles, the potential of making a mistake and lack of privacy at home.

Conclusions: Contraceptive self-injection has the potential to increase contraceptive access and use for adolescents in Uganda, and should be considered as a delivery modality in the context of adolescent-friendly contraceptive services.

Context: Son preference exerts a strong influence over contraceptive and fertility decisions in many South Asian countries. In Pakistan, where fertility remains high and contraceptive use low, research on son preference has been limited.

Methods: Data from Pakistan Demographic and Health Surveys conducted in 1990-1991, 2006-2007 and 2012-2013 were used to examine potential indicators and outcomes of son preference. Descriptive analyses looked at sex composition preferences of men and women, as well as the sex ratio at last birth. Multivariate logistic regression analyses examined parity progression by birth order, while multinomial logistic regression was used to identify associations between sex composition and use of permanent, temporary and traditional contraceptive methods.

Results: Parity progression and choice of contraceptive method are increasingly associated with the sex composition of children. Many respondents wanted at least two sons, though most also wanted at least one daughter. Analyses suggest that the prevalence of modern contraceptive use among parous women would have been 19% higher in 2012-2013 in the absence of son preference. Permanent method use was extremely low among women with no sons and increased significantly with number of sons. The association between number of sons and use of temporary methods was weaker, while son preference had little relationship with traditional method use.

Conclusions: The association of son preference with parity progression and modern contraceptive use has become stronger in Pakistan. Continuation of the fertility transition may be difficult unless the degrees of differential stopping behavior and differential contraceptive use decline.

Context: Despite the commitment of the Democratic Republic of the Congo (DRC) to expand the family planning method mix and increase access to services, awareness of emergency contraception is low among women, and the method remains underused and poorly integrated in family planning programming.

Methods: Data from 15 focus group discussions conducted in 2016 among women aged 15-35 were used to examine awareness and perceptions of, and attitudes toward, emergency contraceptives. After facilitators explained emergency contraceptive pills' mechanism of action and other characteristics, participants were asked about the potential benefits and risks of making the method more widely available. Transcripts were analyzed using an iterative approach.

Results: Women reported employing a wide range of postcoital contraceptive behaviors, albeit often using inappropriate products, and generally agreed that emergency contraceptive pills seemed to be a potentially effective solution to their family planning needs. Perceived benefits and limitations of the method were almost always framed in reference to other, better-known contraceptives, and women expressed strong preferences for pharmacy-based provision that aligned with their usual behaviors for obtaining contraceptives. Participants were reluctant to see the method available for free.

Conclusions: Emergency contraceptive pills have the potential to address gaps in the family planning method mix in the DRC. Assessing whether women have incomplete or erroneous information about family planning methods can provide better understanding of women's contraceptive choices in low-income countries.

Context: According to Demographic and Health Survey (DHS) data, highly educated urban women in some West African countries simultaneously have low rates of both contraceptive use and fertility-suggesting that the DHS may not be capturing a complete picture of women's contraceptive practices.

Methods: Individual in-depth interviews and focus group discussions were conducted with a total of 48 women aged 18-49 in Accra, Ghana, who had at least a secondary education to explore their reproductive lives and relationships, and their views on and use of fertility regulation strategies. Data were analyzed using iterative thematic techniques.

Results: Women commonly reported using combinations of contraceptive methods, including "counting days" (using a calendar and the date of one's last menstrual period to estimate "unsafe" days-those on which the risk of conception is high), as well as withdrawal, condoms and frequent use of emergency contraceptive pills. Women described practicing "periodic contraception": for example, counting days to determine unsafe days and practicing contraception ad hoc on such days. Method use combinations varied from cycle to cycle-forming a "mosaic" of method use combinations over time.

Conclusions: The fertility control strategies commonly reported by the study respondents-periodic contraception, and frequent use of traditional methods and emergency contraceptive pills-are likely not adequately captured in general surveys such as the DHS. Such surveys are also not well suited to measuring combinations of methods and mosaics of method combinations. New ways of capturing women's fertility regulation practices should be considered, including additional survey items, new question modules and specialist studies.

Context: Given the proportion of Kenyan women not using hormonal contraceptives, the country appears to have a substantial need for a modern, natural family planning option. The CycleBeads® mobile phone application (app), a digital platform for the Standard Days Method® of family planning, could help address this issue.

Methods: After the CycleBeads app was promoted in Kenya in May-June 2015, a three-month pilot study was conducted to collect quantitative and qualitative data from 185 female app users. Chi-square testing, binary logistic regression and thematic content analysis were used to assess whether the app brought new users to family planning, to understand users' experiences and to assess how user experiences vary by distribution channel.

Results: Participants learned about the app through nongovernmental organizations (17%), via digital media (33%) or from family or friends (50%). Most used the app to track their periods (54%) or prevent pregnancy (37%); a few used it to plan a pregnancy (7%) or for other reasons (2%). The main reason for choosing the Standard Days Method was fear of side effects from hormonal methods (64%). The majority of women found the app and method easy to use (53%). Among those preventing pregnancy, 42% had never before used a method. By midline, all participants knew when fertile days occurred, and most (97%) knew the method's cycle-length requirements. Women reported high rates of condom use (88%), abstinence (68%) and withdrawal (46%) on fertile days.

Conclusion: Offering the CycleBeads app to support women in use of the Standard Days Method may expand family planning options, reduce unmet need and make family planning more widely available.

Context: Evidence on STI knowledge among Iranian nonmedical university students is limited. Information is needed to inform research and policies to improve the sexual health of university students in Iran.

Methods: A convenience sample of 742 male and female undergraduate and graduate students was recruited from five nonmedical public and private universities in Iran in 2014. Respondents' awareness of and knowledge about STIs were assessed using a validated questionnaire. Chi-square tests, student t tests and one-way analysis of variance were used to compare the percentage of respondents giving correct responses across subgroups of students.

Results: Half of the respondents had ever heard of STIs, but most could not correctly identify STIs in a list of diseases. A total of 49%, 42% and 9% of the respondents had low, moderate and high STI knowledge scores, respectively. Respondents reported online sources (62%) and friends (32%) as their main sources of information about STIs, and those who were older, ever-married or more educated were more knowledgeable than other respondents.

Conclusions: Given that the Internet was students' main source of information, increasing the accessibility and visibility of credible Internet sites about sexual health is warranted. Also, key individuals in students' networks (e.g., parents, teachers, peers) should be equipped with required training and knowledge on STI-related topics and be actively involved in sexual health education efforts.