In this issue of International Perspectives on Sexual and Reproductive Health :
"Meeting Contraceptive Needs: Long-Term Associations of the PRACHAR Project with Married Women’s Awareness and Behavior in Bihar," by Shireen J. Jejeebhoy, Ravi Prakash, Rajib Acharya, Santosh K. Singh and Elkan Daniel
"Empowering Women or Pleasing Men? Analyzing Male Views on Female Condom Use in Zimbabwe, Nigeria and Cameroon," by Winny Koster, Marije Groot Bruinderink and Wendy Janssens
"An Assessment of Family Planning Decision Makers’ and Advocates’ Needs and Strategies in Three East African Countries," by Ellen Smith, Ruth Musila, Violet Murunga and Ramona Godbole
"Contraceptive Dynamics in Rural Northern Malawi: A Prospective Longitudinal Study," by Aisha Nandini Zoe Dasgupta, Basia Zaba and Amelia C. Crampin
Comment: "A Fresh Look at the Level of Unmet Need for Family Planning in the Postpartum Period, Its Causes and Program Implications," by John Cleland, Iqbal H. Shah and Lenka Benova
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IN THIS ISSUE OF INTERNATIONAL PERSPECTIVES:
Reproductive Health Program in India Has Long-Term Positive Results
Positive outcomes linked to a reproductive health program that used multiple approaches were sustained for up to eight years after the end of the program, according to "Meeting Contraceptive Needs: Long-Term Associations of the PRACHAR Project with Married Women’s Awareness and Behavior in Bihar," an evaluation study by Shireen Jejeebhoy of the Population Council et al. Compared with young women living in areas not included in the project, those in the intervention areas were more likely to have knowledge about specific methods of contraception, to have ever used contraceptives or modern methods, and to have initiated contraceptive use within three months of their first birth. These positive differences were found not only among women directly exposed to intervention messages and activities, but for some measures among indirectly exposed women as well.
Marketing the Female Condom to Men as Well as Women May Increase Use
According to "Empowering Women or Pleasing Men? Analyzing Male Views on Female Condom Use in Zimbabwe, Nigeria and Cameroon," a qualitative study by Winny Koster, of the Amsterdam Institute of Global Health and Development, et al., men in all three countries favored the method over other means of protection for its enhancement of sexual pleasure, as well as its effectiveness and lack of side effects. Generally, men preferred using the female condom with stable rather than casual partners, and for contraception rather than HIV protection. In all three countries, men considered it unacceptable for a woman to initiate female condom use, suggesting that marketing the device as a means of female empowerment may not be productive. The authors note that in Sub-Saharan Africa, where decisions about sex and contraception are considered men’s prerogative, marketing strategies aimed at both men and women may be the best way to increase use.
Government Decision Makers Are More Receptive to Family Planning Messages from Local Advocates
According to "An Assessment of Family Planning Decision Makers’ and Advocates’ Needs and Strategies in Three East African Countries," by Ellen Smith of Paladium, et al., key informants in government and nongovernmental organizations in Ethiopia, Kenya and Malawi believe that advocacy has helped to spur favorable shifts in government support of family planning. These decision makers noted, however, that advocacy messages must consider barriers to decision makers’ support for family planning—constituents’ negative attitudes; fear that increased contraceptive use could shrink the size and influence of specific voting blocs and ethnic groups; and competing economic, social, cultural, religious and political priorities. Although decision makers reported valuing the involvement of international family planning organizations and donors, they were more comfortable receiving advocacy messages from local sources who understand the issues and the context.
Women’s Responses to Survey Questions on Contraceptive Use May Overestimate Actual Protection from Unintended Pregnancy
In settings where inconsistent, long-term use of the injectable and other short-term methods is common, the contraceptive prevalence rate calculated from responses to questions in cross-sectional surveys may overestimate the proportion of women protected against unintended pregnancy, according to "Contraceptive Dynamics in Rural Northern Malawi: A Prospective Longitudinal Study," by Aisha Dasgupta et al., of the London School of Hygiene and Tropical Medicine. Contraceptive service data from a one-year prospective study in Karonga, a demographic surveillance site, indicated that only 51% of injectable users received their first reinjection on time, and just 15% received all their reinjections on time during the 12-month study period. In addition, the proportion of women in Karonga using the injectable at seven months after uptake, as estimated from service data (14%), was considerably lower than the proportion estimated from cross-sectional data from the Malawi Demographic and Health Survey (20%), suggesting that the former estimate picked up discontinuation and gaps in coverage not captured by women’s responses to questions about contraceptive use in the survey.
COMMENT
Starting Contraception Soon After a Birth May Not Work for All Women Who Want to Space Pregnancies
Postpartum contraceptive use is important in helping women avoid the health risks of closely spaced births. However, according to "A Fresh Look at the Level of Unmet Need for Family Planning in the Postpartum Period, Its Causes and Program Implications," a Comment by John Cleland of the London School of Hygiene and Tropical Medicine et al., recommendations made on the best timing of contraceptive uptake for new mothers in developing countries must take into account the duration of protection against pregnancy provided by breast-feeding–induced amenorrhea. In countries where the duration of amenorrhea is short, the authors say, recommending immediate or early postpartum initiation of use is valid; however, in countries where amenorrhea typically lasts for around 12 months, as in most of Sub-Saharan Africa, early adoption of family planning provides redundant protection. In addition, high proportions of women in many African countries discontinue their initial method within the first year of use without switching to another; thus, amenorrhea and contraceptive use may end at about the same time, leaving women at risk of unintended pregnancy. In such countries, the authors argue, women should be given the choice of postponing use of contraceptives until amenorrhea ends, along with accurate information on the associated risk of pregnancy.
DIGESTS
Direct Maternal Mortality Among Tanzanian Women Associated with Household’s Distance from Hospital
Increase in STI Risk Seen for Women Using Injectable Contraceptives
No Reduction in Protection Seen Among Women Who Missed HPV Vaccine Doses After the First
Risky Behavior Linked to Awareness of HIV Status Among Colombian Men Who Have Sex with Men
In Nigeria, Anti-Gay Law Associated with Increased Stigma and Discrimination
Self-Assessment at Home Is Feasible for Follow-up of Medical Abortion
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