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76 INTERNATIONAL FAMILY PLANNING PERSPECTIVES, December 1998, Vol. 24, N° 4

00.76.1 - HENSHAW, Stanley K.; SINGH, Susheela; OYE-ADENIRAN, Boniface A.; ADEWOLE, Isaac F.; IWERE, Ngozi; CUCA, Yvette P.

The incidence of induced abortion in Nigeria.

Context: Although abortion is illegal in Nigeria except to save the life of the woman, thousands of women resort to it each year. Information on the incidence of abortion and on the consequences of abortion outside the health care system is needed to develop policies and programs that will address the problem.

Methods: Experienced physicians conducted interviews at a nationally representative sample of 672 health facilities in Nigeria that were considered potential providers of abortions or of treatment for abortion complications. The data were used to estimate the annual number of abortions and to describe the provision of abortion-related services.

Results: Each year, Nigerian women obtain approximately 610,000 abortions, a rate of 25 abortions per 1,000 women aged 15-44. The rate is much lower in the poor, rural regions of northern Nigeria than in the more economically developed southern regions. An estimated 40% of abortions are performed by physicians in established health facilities, while the rest are performed by nonphysician providers. Of the abortions performed by physicians, 87% take place in privately owned facilities and 73% are performed by nonspecialist general practitioners. Three-quarters of physician providers use manual vacuum aspiration to perform abortions, and 51% of providers who treat abortion complications use this method. Physician respondents believe that the main methods used by nurses, midwives and other nonphysicians to induce abortions are dilation and curettage, hormonal or synthetic drugs and insertion of solid or sharp objects.

Conclusions: Although highly restricted, abortions take place in large numbers in Nigeria, under both safe and unsafe conditions. Policies to improve access to contraceptive services would reduce unplanned pregnancy and abortion and, along with greater access to safe abortion, would help preserve the health and lives of Nigerian women.

English - pp. 156-164.

S. K. Henshaw, The Alan Guttmacher Institute, New York, U.S.A.

(NIGERIA, INDUCED ABORTION, ESTIMATES, PHYSICIANS.)

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00.76.2 - VACH, Trinh Huu; BISHOP, Amie; HOA, Vuong Thi; HIEN, Luong Xuan; CHIEN, Tran Dinh; NGUYEN, Tuong I.

The potential impact of introducing pregnancy testing into menstrual regulation services in Vietnam.

Context: Pregnancy testing is not routinely conducted before early abortion procedures (menstrual regulation) in Vietnam; thus, a substantial proportion of women may be undergoing unnecessary procedures.

Methods: Researchers provided pregnancy testing to 923 consecutive women seeking menstrual regulation at a government clinic in rural Thai Binh Province, Vietnam, to determine the proportion of unnecessary procedures being performed. They also estimated the costs and savings of using pregnancy testing before menstrual regulation.

Results: Of women seeking menstrual regulation, 17% had negative pregnancy tests. If this proportion is applicable to Vietnam as a whole, some 136,000 of the estimated 800,000 menstrual regulation procedures performed each year are unnecessary. Overall, these 800,000 procedures cost the Vietnamese government about $2.2 million a year and cost women about $7 million. By providing pregnancy tests for all women seeking menstrual regulation (at a total cost of $720,000), the government would avoid spending $380,000 for unnecessary procedures, for a net testing cost of $340,000. Assuming costs of more than $12.00 per menstrual regulation procedure for women with complications and $8.50 for those with none, the avoidance of unnecessary procedures would save Vietnamese women an estimated total of $1.2 million.

Conclusions: Increased access to pregnancy testing, combined with improved clinical protocols for determining pregnancy status, could prevent a substantial proportion of unnecessary procedures, resulting in reduced health risks and substantial cost savings for women.

English - pp. 165-169.

T. H. Vach, Research Center for Rural Population and Health, Thai Binh Medical College, Thai Binh, Viet Nam.

(VIET NAM, MENSTRUATION DISORDERS, PREGNANCY TESTS, PROGRAMME EVALUATION, COST-BENEFIT ANALYSIS.)

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00.76.3 - SCHULER, Sidney Ruth; HOSSAIN, Zakir.

Family planning clinics through women's eyes and voices: A case study from rural Bangladesh.

Context: The voices and views of clients are an essential, but often neglected, aspect in initiatives to improve the quality of care provided by family planning and reproductive health programs.

Methods: In anticipation of an increased emphasis on clinic-based services in Bangladesh's national family planning program, a small qualitative study was undertaken in six villages in late 1996. In-depth interviews were conducted with 34 clients of six government and two nongovernment clinics, and researchers spent one day at each clinic observing how providers and clients interacted.

Results: Hierarchical modes of interaction and poor communication dominated many of the encounters, and women had to beg for services in some clinics. Providers appeared to selectively apply interpersonal skills and common courtesy; rudeness to clients was not merely a reflection of ignorance, since the paramedics appeared to know the basic principles of counseling. Limited access to medication and often arbitrary ways of determining when to dispense it created suspicion and tension between providers and clients. Most clients expressed a willingness to overlook rude treatment, long waits and unhygienic conditions, saying that because they were poor, they could not expect better care and had no service alternatives.

Conclusions: Technical solutions, such as training in counseling, may not be enough to improve the quality of care provided in clinics in rural Bangladesh. Institutional policies, norms and incentives need to become more client-oriented if the transition from in-home delivery to clinics is to be a success.

English - pp. 170-175.

S. R. Schule, JSI Research and Training Institute, Arlington, VA, U.S.A.

(BANGLADESH, FAMILY PLANNING PROGRAMMES, PROGRAMME EVALUATION, QUALITY CONTROL, FAMILY PLANNING PERSONNEL.)

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00.76.4 - CARLSON, Elwood; OMORI, Megumi.

Fertility regulation in a declining state socialist economy: Bulgaria, 1976-1995.

Context: Although reproductive behavior in eastern Europe is believed to have altered with the decline of the state socialist systems, there are few data available with which to elucidate changes.

Methods: Findings from a 1976 World Fertility Survey of married women and from a 1995 survey of married and unmarried women are used to assess changes in contraceptive usage during a two-decade time period in Bulgaria. Data on the number of births and abortions from the country's vital and health statistics system are then used to analyze corresponding changes in reproductive outcomes.

Results: Among married women aged 15-44, use of modern contraceptive methods increased from 6% in 1976 to 46% in 1995, while their reliance on traditional methods decreased from 70% to 40%. The proportion of women using no method decreased from 25% in 1976 to 14% in 1995. Although married women under the age of 20 did not increase their practice of contraception as much as women aged 20-44, their reliance on modern methods increased from 1% in 1976 to 18% in 1995. During the same 20-year time period, an increasing share of pregnancies ended in abortion, while live births declined in relative frequency. In 1976, 49% of all pregnancies ended in abortion; by 1995, the proportion had increased to 57%.

Conclusions: Concurrent with an increase in the practice of contraception, Bulgarian women's reliance on induced abortion also increased. The trend evidenced in Bulgaria provides a fresh example of a multiphasic response: A strong stimulus (in this case a declining economy) created an urgency among Bulgarians to control their fertility by all available options.

English - pp. 184-187.

E. Carlson and M. Omoni, Department of Sociology, University of South Carolina, Columbia, SC, U.S.A.

(BULGARIA, FERTILITY TRENDS, ECONOMIC RECESSION, CONTRACEPTIVE USAGE, INDUCED ABORTION.)

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00.76.5 - STEIN, Karen; MEASHAM, Diana; WINIKOFF, Beverly.

The quality of family planning services for breastfeeding women in Senegal.

Context: Women who are breastfeeding need access to family planning information and services to help them choose a contraceptive method that allows them to sustain breastfeeding and that is safe for the breastfeeding child.

Methods: Data from an operations research study of all family planning service delivery sites in Senegal were used to assess the management of contraceptive services for lactating women visiting the clinics for the first time.

Results: At the time of the site visits, nearly 60% of the women visiting the family planning clinics for the first time were breastfeeding. Although most providers knew the correct advice to give breastfeeding women, 21% of the women were not asked their breastfeeding status during the clinic visit, and more than one-third accepted estrogen-containing contraceptives (which are not recommended for breastfeeding women). Overall, estrogen-containing contraceptives were less likely to have been accepted by breastfeeding women than by women who were not breastfeeding; however, among women known by the provider to be breastfeeding, estrogen-containing methods and progestin-only pills were accepted at the same frequency as among women who were not asked their breastfeeding status.

Conclusions: In order to meet the needs of breastfeeding women, providers must have correct information about the appropriate use of all contraceptive methods during lactation. Additionally, the reasons that providers do not ascertain breastfeeding status or give appropriate contraceptive advice to lactating women need to be identified.

English - pp. 188-190.

K. Stein, Population Council, New York, U.S.A.

(SENEGAL, FAMILY PLANNING PROGRAMMES, BREAST FEEDING, CONTRACEPTIVE METHODS.)

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76 INTERNATIONAL FAMILY PLANNING PERSPECTIVES, September 1999, Vol. 25, N° 3

00.76.6 - BOULAY, Marc; VALENTE, Thomas W.

The relationship of social affiliation and interpersonal discussion to family planning knowledge, attitudes and practice.

Context: Past research has demonstrated an association between membership in a social club and the adoption of family planning, yet little is known about the how these groups promote the diffusion of such behavior.

Methods: Data on 2,217 women aged 15-49 and 2,152 men aged 15-54 from the 1994 Kenya Situation Survey are used to examine the role of communication within individuals' social networks in mediating the association between club membership and awareness, approval and use of family planning.

Results: In analyses accounting for demographic factors, women club members were 2.3 times as likely as nonmembers to know about modern methods of family planning, and male club members were 1. 5 times as likely as nonmembers to know about modern contraceptives and 1.7 times as likely as nonmembers to approve of family planning. Club membership was not directly associated with increased use of contraceptives, but among both men and women, participation in a club was associated with significantly greater odds of having family planning discussions with members of both core and extended social networks. Women who had discussed family planning with both core and extended network members were 8.3 times as likely to be currently using modern contraceptives, and men who had done so were 3.2 times as likely as were those who had limited such discussions to their core network only.

Conclusions: By promoting informal discussions about family planning within a group with a diverse membership, social clubs play a mediating role in the diffusion of new information and innovative behaviors.

English - pp. 112-118.

M. Boulay, Center for Communication Programs, The Johns Hopkins University, Baltimore, MD, U.S.A.

(KENYA, INFORMATION NETWORKS, INFORMATION DISSEMINATION, INTERPERSONAL COMMUNICATION, CONTRACEPTIVE PREVALENCE, KNOWLEDGE OF CONTRACEPTIVES.)

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00.76.7 - HUBACHER, David; HOLTMAN, Matthew; FUENTES, Miriam; PEREZ-PALACIOS, Gregorio; JANOWITZ, Barbara.

Increasing efficiency to meet future demand: Family planning services provided by the Mexican ministry of Health.

Context: With fewer external funds for family planning programs and a growing reliance on the public sector for services, developing countries will need to find new resources if they are to maintain existing levels of service. By estimating the costs of services and evaluating the service delivery system for inefficiencies, a better understanding of future resource needs can be achieved.

Methods: Data for this study were collected in 1996 at 82 Mexican Ministry of Health facilities, which included observations of providers and ancillary information for estimating costs of services. The cost per minute of provider labor was used to estimate the cost of various types of family planning visits and the cost per couple-year of protection for different contraceptive methods. Some service delivery parameters were modified hypothetically to estimate the effects on costs.

Results: Mexico's Ministry of Health is currently spending approximately $29 per person per year on contraceptive services. As demand increases, the system can be made more efficient by increasing the length of providers' workday and the proportion of time they spend with clients, and by dispensing more contraceptive protection at each visit. Increasing the proportion of time a provider spends with clients will reduce the cost per couple-year of protection for all methods. Doubling the number of pill cycles distributed during a visit reduces the cost per couple-year of protection from $27 to $19. Providing twice as many condoms per visit reduces the overall cost per couple-year of protection from $29 to $19. If providers lengthen their workday, increase the amount of time they spend with clients and dispense more contraceptives during a visit, the overall cost per couple-year of protection would decline from the 1995 level of $29 to $22 by 2010.

Conclusions: Correcting the service delivery inefficiencies that exist in their current system should enable the Mexican Ministry of Health to meet the rising demand for services without expanding current programs through the next decade.

English - pp. 119-124.

D. Hubacher and M. Holtman, Family Health International, Research Triangle Park, NC, U.S.A.

(MEXICO, FAMILY PLANNING PROGRAMMES, PROGRAMME EVALUATION, PUBLIC SERVICES.)

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00.76.8 - GUPTA, Neeru; DA COSTA LEITE, Iúri.

Adolescent fertility behavior: Trends and determinants in northeastern Brazil.

Context: Much of the recent decline in Brazil's total fertility rate has been observed among women in the middle of their reproductive years. In contrast, the contribution of adolescent fertility (among 15-19-year-olds) to the total fertility rate is increasing over time. This trend is particularly accentuated in the country's Northeast region.

Methods: Data from three Demographic and Health Surveys conducted in Northeastern Brazil in 1986, 1991 and 1996 are used to examine trends and determinants of fertility behavior among adolescents in the region. Discrete-time hazard models are used to estimate the probability of a woman having a first birth during adolescence, and to evaluate individual and environmental factors that may influence personal fertility choices.

Results: A young woman's level of education is the factor most strongly and consistently associated with the probability of giving birth during adolescence. In particular, an adolescent with no more than primary schooling is more than twice as likely to have had a first birth than an adolescent with at least a secondary education, even after the analysis is controlled for age, time period and other characteristics. Religious affiliation and mass media exposure did not consistently affect adolescent fertility over time in the multivariate analysis.

Conclusions: The promotion of education may be the most effective means of encouraging delayed childbearing among adolescents in Northeastern Brazil. There is a need for greater research into the impact of community facilities on teenage fertility, notably health and family planning programs, that target adolescents.

English - pp. 125-130.

N. Gupta, Département de démographie, Université de Montréal, Montréal, Canada.

(BRAZIL, REGIONS, ADOLESCENT FERTILITY, FERTILITY DETERMINANTS, LEVELS OF EDUCATION, DIFFERENTIAL FERTILITY.)

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00.76.9 - NAZAR-BEUTELSPACHER, Austreberta; MOLINA-ROSALES, Dolores; SALVATIERRA-IZABA, Benito; ZAPATA-MARTELO, Emma; HALPERIN, David.

Education and nonuse of contraceptives among poor women in Chiapas, Mexico.

Context: Relatively little is known about how poverty and illiteracy affect women's decisions to adopt contraception, specifically their likelihood of never having practiced contraception.

Methods: A random sample of 883 women in union aged 15-49 living in the Border Region of the Mexican state of Chiapas were interviewed in 1994 as part of a regional survey of reproductive health. Multivariate logistic regression analyses were performed for the sample as a whole and for individual age-groups to determine the relationship between socioeconomic variables and the likelihood that a woman had never practiced contraception.

Results: The lack of any schooling at all was independently associated with the likelihood of nonuse of contraceptives, as illiterate women were 1.6 times as likely as those who attended secondary school to have never practiced contraception. Other socioeconomic variables that also independently raised the likelihood of nonuse were delivering at home, having experienced the death of at least two children and not having paid employment at the time of the survey. The effect of schooling on the likelihood of nonuse varied by age: While never having been to school increased that likelihood among both the youngest and oldest women, the magnitude of the effect lessened over time. Moreover, among younger women, socioeconomic variables other than school attendance were more important in explaining nonuse.

Conclusions: The increased availability of family planning services in the Border Region of Chiapas over the last 20 years has weakened the direct effect of schooling on contraceptive practice. However, having never been to school remains a strong predictor of never-use of contraceptives in this population.

English - pp. 132-138.

A. Nazar-Beutelspacher, Colegio de Postgraduados, Texcoco, Estado de México, Mexico.

(MEXICO, REGIONS, CONTRACEPTIVE USAGE, LEVELS OF EDUCATION.)

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00.76.10 - ABRAHAM, Leena; KUMAR, K. Anil.

Sexual experiences and their correlates among college students in Mumbai City, India.

Context: Isolated studies indicate that pregnancy and sexually transmitted diseases are on the rise among unmarried teenagers in India. However, little research has focused on sexual behavior among unmarried young people, partly because of the assumption that it is governed by traditional norms.

Methods: Results of a 1997 survey conducted among 966 low-income college students in metropolitan Mumbai (Bombay) are examined to identify levels of sexual behavior. Multivariate analysis is used to determine correlates of that behavior.

Results: Some 47% of male participants and 13% of female respondents had had any sexual experience with a member of the opposite sex, 26% and 3%, respectively, had had intercourse. Individual-level characteristics such as age and personal income had modest effects on students' sexual behavior, and family-level variables had no significant effects. The strongest predictors of sexual behavior were students' knowledge about sexuality-related issues, attitudes toward sex, and levels of social interaction and exposure to erotic materials. However, the results differed for young men and women, and the effect of knowledge was inconsistent.

Conclusions: Traditional norms and the role of the family are losing their importance in governing young people's sexual behavior in India. School-based sexuality programs are needed that will provide students with accurate information about pregnancy, contraception and sexually transmitted diseases.

English - pp. 139-146.

L. Abraham and K. A. Kumar, Tata Institute of Social Sciences, Bombay, India.

(INDIA, CITIES, STUDENTS, SURVEYS, SEXUAL BEHAVIOUR, SEX EDUCATION.)

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