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76 INTERNATIONAL

FAMILY PLANNING PERSPECTIVES

June 1998, Vol. 24, N° 2

99.76.6 - RAHMAN, Anika; KATZIVE, Laura; HENSHAW, Stanley K.

A global review of laws on induced abortion, 1985-1997.

Context: The legal status of induced abortion helps determine the availability of safe, affordable abortion services in a country, which in turn influences rates of maternal mortality and morbidity. It is important, therefore, for health professionals to know both the current status of abortion laws worldwide and the extent to which those laws are changing.

Methods: Abortion-related laws in 152 nations and dependent territories with populations of one million or more were reviewed, and changes in these laws since 1985 were documented.

Results: Currently, 61% of the world's people live in countries where induced abortion is permitted either for a wide range of reasons or without restriction as to reason; in contrast, 25% reside in nations where abortion is generally prohibited. However, even in countries with highly restrictive laws, induced abortion is usually permitted when the woman's life is endangered; in contrast, even in nations with very liberal laws, access may be limited by gestational age restrictions, requirements that third parties authorize an abortion or limitations on the types of facilities that perform induced abortions. Since 1985, 19 nations have significantly liberalized their abortion laws; only one country has substantially curtailed legal access to abortion.

Conclusions: A global trend toward liberalization of abortion laws observed before 1985 appears to have continued in more recent years. Nevertheless, women's ability to obtain abortion services is affected not just by the laws in force in a particular country, but also by how these laws are interpreted, how they are enforced and what the attitude of the medical community is toward abortion.

English - pp. 56-64.

A. Rahman et L. Katzive, Center for Reproductive Law and Policy, New York, U.S.A.

(WORLD, INDUCED ABORTION, LEGISLATION, ABORTION POLICY, COMPARATIVE ANALYSIS, TRENDS)

99.76.7 - GÖRGEN, Regina; YANSANÉ, Mohamed L.; MARX, Michael; MILLIMOUNOU, Dominique.

Sexual behavior and attitudes among unmarried urban youths in Guinea.

Context: In Guinea, modern contraceptive use is low, sexuality education is not part of the school curriculum and many young people are sexually active. Understanding what influences young people's sexual behavior and the consequences of that behavior may facilitate the design of effective pregnancy and disease prevention strategies.

Methods: In 1995, 3,603 unmarried men and women aged 15-24 in three towns were surveyed, and 25 focus groups were conducted, to explore young people's sexual behavior and related attitudes.

Results: The average age at first intercourse is 16.3 years for young women and 15.6 for young men. While the first sexual partner typically is a peer, the majority of young women later become involved with older, wealthy partners, whom they view as more attractive spouses than young men or as more likely to provide support if they become pregnant. Young males, who feel they cannot compete with older, wealthy men, have sex with much younger females. More than half of sexually active respondents have never used a contraceptive; 29% have used a condom. A quarter of the young women have been pregnant, and 22% of these have had an abortion.

Conclusions: Young people are exposed to health hazards through their sexual behavior, and timely gender-specific sexuality education must be made available. School-based sexuality education could benefit even out-of-school youths, because their partners often are students.

English - pp. 65-71.

R. Görgen, Institute of Tropical Hygiene and Public Health, University of Heidelberg, Germany.

(GUINEA, URBAN ENVIRONMENT, YOUTH, SEXUAL BEHAVIOUR, ATTITUDE, SEX EDUCATION)

99.76.8 - GRAHAM, Maureen J.; LARSEN, Ulla; XU, Xiping.

Son preference in Anhui province, China.

Context: Chinese couples, particularly those in rural areas, have historically had a strong preference for sons. This preference may affect couples' reproductive behavior and their treatment of girl vs. boy children.

Methods: A community-based household survey was conducted in two rural counties of Anhui Province in 1993. Responses from 5,779 women of reproductive age who had had at least one birth yielded data on sex ratios, duration of breastfeeding and childbearing patterns.

Results: The overall sex ratio was 1.18 male births per female birth, significantly higher than the expected ratio of 1.06; for first, second and third or higher order births, ratios were 1.17, 1.12 and 1.16, respectively. The sex ratio was low in 1980-1986, when the national one-child policy was strictly enforced, and was significantly elevated before 1980 (1.18) and in 1987-1993 (1.22). Last-born children, regardless of family size, had the highest sex ratio. Girls were breastfed for a significantly shorter duration than boys, particularly if they had an older sister and no brothers. Since 1980, couples with only a girl have been slightly more likely than those with only a boy to have a second child; those with two girls have been 5-6 times as likely as those with two boys to have a third child. The interval between pregnancies is shorter when the previous child was a girl than when the previous child was a boy.

Conclusions: Couples in Anhui control the size of their families and attempt to control the sex composition. If China's fertility decline continues and the preference for sons remains unchanged, discrimination against girls may intensify.

English - pp. 72-77.

M. J. Graham, Department of Environmental Health, Harvard School of Public Health, Boston, MA, U.S.A.

(CHINA, PROVINCES, RURAL ENVIRONMENT, SEX PREFERENCE, SEX RATIO, FAMILY PLANNING PROGRAMMES)

99.76.9 - THAPA, Shyam; FRIEDMAN, Matthew.

Female sterilization in Nepal: A comparison of two types of service delivery.

Context: During the last 30 years, outreach camps have played an increasingly important role in Nepal's family planning program, by bringing sterilization services to mostly rural areas where they otherwise would not have been available. However, some concerns have been raised about differences in the social and demographic characteristics and quality of care between permanent and seasonal or mobile service delivery sites.

Methods: From a nationally representative sample of 8,429 ever-married women aged 15-49 who participated in the 1996 Nepal Family Health Survey, samples of 445 women who had been contraceptively sterilized in hospitals and 372 in camps were compared for their social and demographic characteristics, awareness of alternative contraceptive methods, first contraceptive method used and regret over having undergone the procedure.

Results: Women who were sterilized in camp settings and those sterilized in hospitals differed in their place and region of residence, although both groups were similar in age and parity at the time of sterilization. Roughly 92% of hospital clients and 95% of camp clients knew about at least one temporary contraceptive method. Four out of five hospital and camp clients reported that female sterilization was the first method they had ever used (80% and 82%, respectively). Nearly 12% of women who were sterilized in hospitals and 10% of women who underwent the procedure in camps expressed regret.

Conclusions: Camps do not imply less careful screening of sterilization clients or the provision of inferior quality services, and they represent an important means of meeting couples' demand for sterilization services in areas where hospital- or clinic-based services are not available throughout the year.

English - pp. 78-83.

S. Thapa, Family Health International, Research Triangle Park, NC, U.S.A.

(NEPAL, SEXUAL STERILIZATION, FEMALE STERILIZATION, CAMPS, HOSPITALS, COMPARATIVE ANALYSIS)

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76 INTERNATIONAL

FAMILY PLANNING PERSPECTIVES

September 1998, Vol. 24, N° 3

99.76.10 - KATZ, Karen R.; WEST, Caroline G.; DOUMBIA, Fodé; KANÉ, Fatoumata.

Increasing access to family planning services in rural Mali through community-based distribution.

Context: Community-based contraceptive distribution (CBD) has been the subject of relatively few quantitative studies, despite the use of these programs in a number of areas where contraceptive prevalence is low.

Methods: A CBD program was incorporated into a nongovernmental organization's primary health care system in two subdistricts in rural southern Mali. In two other subdistricts, information and education alone were provided by primary health care workers. A fifth subdistrict served as a control group. Contraceptive knowledge, attitudes and practices were measured prior to program implementation in a pretest survey of 2,994 women and men. After 18 months, a posttest survey of 2,551 women and men was conducted.

Results: Women's knowledge of at least one modern contraceptive method was greater after the intervention than before for all three groups: 99% vs. 10% in the CBD group, 71% vs. 10% in the education-only group and 53% vs. 10% in the control group. Women's current use of a modern contraceptive method also increased, from 1% to 31% in the CBD group, from 1% to 10% in the education-only group, and from 2% to 14% in the control group. Oral contraceptives and spermicides were the most popular methods in the CBD group, while the pill accounted for almost all contraceptive use in the education-only and control groups. Similarly, men's ever-use of condoms increased from 9% to 35% in the CBD group and from 7% to 16% in the education-only group, compared with use levels of 6% vs. 10% in the control group.

Conclusions: The CBD approach tested in rural Mali raised contraceptive knowledge and practice through use of an existing health care framework, and may be a model for those working to expand and improve family planning programs elsewhere in Africa.

English - pp. 104-110.

K. R. Katz and C. G. West, Family Health International, Research Triangle Park, NC, U.S.A.

(MALI, RURAL ENVIRONMENT, PROGRAMME DE PLANNING FAMILIAL, CONTRACEPTIVE DISTRIBUTION, PRIMARY HEALTH CARE, METHODOLOGY)

99.76.11 - AGADJANIAN, Victor.

"Quasi-legal" abortion services in a sub-Saharan setting: Users' profile and motivations.

Context: Because induced abortion is illegal in most of Sub-Saharan Africa, information about why women may wish to terminate a pregnancy is difficult to obtain. Mozambique, where induced abortion is officially banned but is available on request in a number of hospitals, provides an opportunity to examine the characteristics and motivations of abortion patients.

Methods: Analysis of data from the maternity ward records of an urban hospital provide a profile of 394 women who sought abortions in May-July 1993.

Results: While large proportions of the women obtaining "quasi-legal" abortions were younger than 30 (74%), not in a union (58%) and in school (36%), the proportions who were older, married and working considerably exceeded those found among women obtaining clandestine abortions in Sub-Saharan Africa. Material difficulties and the desire to continue studies were the most common reasons women cited for seeking an abortion, given by 41% and 30%, respectively. However, many women with children decided to have an abortion because they wanted either to postpone the next birth or to cease childbearing. Few women gave contraceptive failure or the conflict between work and childbearing as a reason for abortion.

Conclusions: Women's socioeconomic circumstances may affect their attitudes toward and ability to obtain an induced abortion. Legalization of the procedure would help extend services to underserved segments of the population, but greater access for poor, rural women will depend on the nation's socioeconomic progress.

English - pp. 111-116.

V. Agadjanian, Department of Sociology, Arizona State University, Tempe, U.S.A.

(MOZAMBIQUE, INDUCED ABORTION, CLIENTS, HOSPITALS, SOCIO-ECONOMIC CONDITIONS)

99.76.12 - BANKOLE, Akinrinola; SINGH, Susheela; HAAS, Taylor.

Reasons why women have induced abortions: Evidence from 27 countries.

Context: The immediate explanation that women often give for seeking induced abortion is that the pregnancy was unplanned or unwanted. However, the myriad social, economic and health circumstances that underlie such explanations have not yet been fully explored.

Methods: Findings from 32 studies in 27 countries were used to examine the reasons that women give for having an abortion, regional patterns in these reasons and the relationship between such reasons and women's social and demographic characteristics. The data come from a range of sources, including nationally representative surveys, official government statistics, community-based studies and hospital- or clinic-based research.

Results: Worldwide, the most commonly reported reason women cite for having an abortion is to postpone or stop childbearing. The second most common reason-socioeconomic concerns-includes disruption of education or employment; lack of support from the father; desire to provide schooling for existing children; and poverty, unemployment or inability to afford additional children. In addition, relationship problems with a husband or partner and a woman's perception that she is too young constitute other important categories of reasons. Women's characteristics are associated with their reasons for having an abortion: With few exceptions, older women and married women are the most likely to identify limiting childbearing as their main reason for abortion.

Conclusions: Reasons women give for why they seek abortion are often far more complex than simply not intending to become pregnant; the decision to have an abortion is usually motivated by more than one factor. While improved contraceptive use can help reduce unintended pregnancy and abortion, some abortions will remain difficult to prevent, because of limits to women's ability to determine and control all circumstances of their lives.

English - pp. 117-127 and 152.

A. Bankole, S. Singh and T. Haas, The Alan Guttmacher Institute, New York, NY, U.S.A.

(INDUCED ABORTION, SOCIAL PSYCHOLOGY, UNWANTED PREGNANCY, SOCIO-ECONOMIC CONDITIONS)

99.76.13 - AHMED, M. Kapil; RAHMAN, Mizanur; VAN GINNEKEN, Jeroen.

Induced abortion in Matlab, Bangladesh: Trends and determinants.

Context: Although many women in Bangladesh resort to abortion when confronted with an unwanted pregnancy, neither the incidence of induced abortion nor the characteristics of women who rely on abortion have been well studied.

Methods: Data from a longitudinal demographic surveillance system are used to analyze the outcomes of about 75,000 pregnancies between 1982 and 1991 in Matlab, a rural area of Bangladesh. Outcomes among women in the Matlab treatment area, who have access to an intensive maternal and child health and family planning program, are compared with those among women in a comparable neighboring area who receive the standard government-sponsored services.

Results: The ratio of induced abortions to live births increased in both the treatment and comparison area-from 15 per 1,000 in 1982 to 29 per 1,000 in 1991 in the treatment area and from 12 to 45 per 1,000 in the comparison area. The incidence of abortion was higher among women who had had six or more births or who became pregnant fewer than 12 months after the previous pregnancy. Induced abortion ratios were higher among users of the pill, condoms or traditional methods than among users of injectable contraceptives or among contraceptive nonusers. In most subgroups, women in the treatment area were less likely to have obtained an abortion than were those in the comparison area. Abortion ratios in the treatment area began falling after 1992, and returned to 16 per 1,000 by 1995.

Conclusions: A high-quality reproductive health program offering use-effective contraceptive methods can reduce the burden of induced abortion in Bangladesh.

English - pp. 128-132.

M. K. Ahmed, M. Rahman and J. van Ginneken, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh.

(BANGLADESH, INDUCED ABORTION, TRENDS, FAMILY PLANNING PROGRAMMES)

99.76.14 - SHAH, Nasra M.; SHAH, Makhdoom A.; RADOVANOVIC, Zoran.

Patterns of desired fertility and contraceptive use in Kuwait.

Context: Despite moderate levels of contraceptive use and a rapidly changing socioeconomic structure, fertility remains high in Kuwait. Little is known about what factors characterize women in a highly pronatalist society who have smaller families.

Methods: Interviews were conducted from January to March 1994 with a random sample of 615 currently married, nonpregnant Kuwaiti women aged 15-49 in two of the country's five major residential areas. Regression analyses were used to determine the predictors of ideal family size, desire for another child and contraceptive use.

Results: The mean ideal number of children desired by Kuwaiti women was 5.3. Fifty percent of the women were practicing contraception, mainly to space births. Forty-one percent said they wanted no more children, but only 45% of them were using a method. In comparison with non-Bedouins and women with fewer living children, Bedouins and women with more children desired significantly larger families and were significantly less likely to say they wanted to stop childbearing. Contraceptive use was significantly higher among non-Bedouins, women who had reached or exceeded their ideal number of children and those who had a primary or secondary education, and it rose with the number of living children and the husband's level of education.

Conclusions: In a social setting that encourages high fertility, number of living children and ethnic background are the most important factors in whether women want to stop childbearing and whether they use contraceptives, as well as in how many children they consider ideal.

English - pp. 133-138.

N. M. Shah, Department of Community Medicine, Faculty of Medicine, Kuwait University, Koweit.

(KUWAIT, FERTILITY DETERMINANTS, CONTRACEPTIVE USAGE, IDEAL FAMILY SIZE)

99.76.15 - MURRAY, Nancy J.; ZABIN, Laurie S.; TOLEDO-DEVRES, Virginia; LUENGO-CHARATH, Ximena.

Gender differences in factors influencing first intercourse among urban students in Chile.

Context: While many surveys have documented trends in adolescent sexuality and fertility in Latin America, relatively few data are available that describe factors associated with the onset of sexual activity in a Latin American context.

Methods: Variables hypothesized to be associated with early sexual debut, such as family structure, parental education, academic performance, peer-group influences, use of drugs and alcohol, and attitudes toward sexuality and early parenthood, were examined through multivariate logistic regression techniques among a sample of 4,248 urban Chilean students aged 11-19.

Results: Overall, 21% of the young women and 36% of the young men had ever had sex, with the median ages of first intercourse being 15 years and 14 years, respectively. In the bivariate analyses, the father's absence from the home was significantly associated with early sexual initiation among female students but not among males; however, regardless of gender, students with more liberal attitudes toward sex, those who thought most of their peers were sexually experienced, those who rarely attended religious services, those who had ever used alcohol, tobacco or marijuana, and those with lower grade-point averages were all more likely to have ever had sex. In the final reduced model, there were few differences by gender in the attitudinal, behavioral and social relations factors that were significantly related to sexual debut, although father's presence in the home and academic achievement were still significant in the final model for young women only.

Conclusions: Enough young people initiate sexual activity in the early teenage years to warrant offering sex education sooner than is now the case. Courses might thus include specific information on contraception, as well as take into account the ways in which adolescent attitudes, risk behaviors and familial and academic environments shape choices related to sexual behavior.

English - pp. 139-144 and 152.

N. J. Murray and L. S. Zabin, Department of Population Dynamics, Johns Hopkins University, Baltimore, MD, U.S.A.

(CHILE, ADOLESCENT FERTILITY, SEXUAL BEHAVIOUR, SEX EDUCATION)

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