A preference for sons is deeply rooted in many cultures. The greater value placed on sons than on daughters not only results in inequitable treatment of male and female children, but also affects individual fertility behavior, population fertility levels and family planning needs, as the first two articles in this issue show.

As ideal family size decreases in many countries, couples may find it difficult to have the number of sons they want without surpassing their desired number of children. Where prenatal sex determination and abortion are available, couples may resort to sex-selective abortion to achieve that goal. Otherwise, if their desire for sons leads them to continue childbearing, the result may be a larger-than-desired family. Using data from India’s 2005–2006 National Family Health Survey, Sanjukta Chaudhuri found that women with more sons than daughters were generally less likely than those with more daughters than sons to have another child; parity progression driven by a desire for sons accounted for 7% of births [page 178]. At any given parity, the last-born child of women who had stopped childbearing was more likely to be a son than a daughter. And although couples generally wanted at least one daughter, women without any sons were more likely than those without any daughters to continue childbearing at parities one through four. Given these findings, the author argues, policies that challenge the perception that sons are more valuable than daughters are as critical as those that seek to reduce family size.

Son preference also has implications for family planning programs. In India, where women marry and start childbearing early, many have had 2–3 children—the current family size norm—by their early 20s. Typically, women are sterilized after they have achieved their desired family size; the mean age at sterilization was 25 in 2005–2006, with eight in 10 women having been sterilized by age 30. Given these factors, Abhishek Singh and colleagues explored the prevalence of and characteristics associated with sterilization regret among Indian women [page 187]. According to data from the 2005–2006 National Family Health Survey, 5% of sterilized women of reproductive age reported regret. Compared with women having only sons, those having only daughters were more likely to express regret, while those having both sons and daughters were less likely to do so. Women who had experienced the death of a child had higher odds of reporting regret than women who had not. In addition, women sterilized at age 30 or older were less likely than those sterilized before age 25 to express regret. The authors recommend that the Indian family planning program consider encouraging couples to delay sterilization and increasing the availability of highly effective reversible contraceptives.

According to analyses of data from the National Youth Reproductive Health Survey by Wei Guo and colleagues, the mean age at sexual debut was 22.5 years for mean and 23.1 years for women in 2009, and debut before age 18 was rare for both sexes [page 196]. Living in a household with both biological parents, having a father with a junior or senior high school education, being a college graduate and living in an urban area were associated with a reduced risk of sexual debut. Noting that only 35% of the respondents had had any formal sex education, and that more than half of Chinese youth do not use contraceptives at sexual debut, the authors suggest that sex education and public health programs be improved to inform Chinese youth about ways to protect themselves against STIs and unwanted pregnancy.

Using Maternal Death Review Reports from 25 refugee camps in 10 countries, Michelle Hynes and colleagues analyzed causes of death; delays in women seeking, reaching and receiving care; and other aspects of case management [page 205]. Seventy-eight percent of the 108 maternal deaths for which reports were available followed delivery or abortion (which is not legal in most camp facilities), and 56% of those deaths occurred within 24 hours. Obstetric hemorrhage was the most common direct cause of death, followed by hypertensive disorders of pregnancy and pregnancy-related sepsis. Delays in seeking and receiving care were more common than delays in reaching care.

Also in This Issue

In a special report, Theresa Hoke and colleagues examine lessons learned from the introduction of community-based distribution of injectable contraceptives in four Sub-Saharan African countries [page 214]. In each country, the provision of injectables was added to pre-existing community-based family planning programs, and only a subset of community health workers who satisfied specific criteria were trained as providers. With eventual scale-up in mind, interventions were kept as simple and low-cost as possible. To build the capacity to maintain and expand these services, introductory strategies maximized the involvement of existing local program partners, such as public-sector trainers and NGOs. Common challenges included limitations in clinicians’ availability to supervise health workers, problems ensuring the timely resupply of commodities, and reporting differences. —The Editors