In many South Asian countries, a preference for sons over daughters not only results in social systems in which women and girls have little agency and low social status, but may suppress the use of modern contraceptive methods and elevate fertility rates as women and couples attempt to reach their desired family composition. In the lead article of this issue of International Perspectives on Sexual and Reproductive Health, Melanie Dawn Channon uses Demographic and Health Survey data to identify potential indicators and outcomes of son preference in Pakistan—a country with historically high fertility rates and limited use of modern contraceptive methods. According to her findings, a woman is less likely to give birth to additional children once she has had two sons, and modern contraceptive use is least common among women who have borne only daughters. Her findings, the author says, suggest that son preference must be addressed if Pakistan is to succeed in increasing use of modern contraceptives and lowering its high fertility rate.

Demographic and Health Survey (DHS) data in some West African countries show that highly educated urban women simultaneously have low rates of contraceptive use and fertility. Using interviews and focus group discussions, Cicely Marston and colleagues found that in Ghana, many such women avoid modern hormonal methods because of fear of perceived side effects. They rely instead on combinations of methods such as "counting days" (using a calendar and the date of their last menstrual period to estimate unsafe days—those on which the risk of conception is high), withdrawal and condoms, as well as frequent use of emergency contraceptive pills. Women also described using "periodic contraception," a practice in which they might, for example, count days to identify unsafe days, and practice contraception ad hoc on those days. The women's responses indicated that they may not consider these practices as "methods" and therefore may not report them as such in the DHS or other household surveys. Because of this, the authors conclude, household surveys in Ghana may not capture common contraceptive practices in the country, leading to estimates of contraceptive prevalence that are out of line with fertility levels.

In the Democratic Republic of the Congo, which has the second highest fertility rate and the second lowest modern contraceptive prevalence rate in Sub-Saharan Africa, knowledge of and access to emergency contraceptive pills remain limited. Using data from focus group discussions with 169 women aged 15–35 in Kinshasa, Julie H. Hernandez and colleagues found that although emergency contraceptive pills were available in the city, most participants were not familiar with them and were instead using folk remedies and noncontraceptive drugs after sex to avoid pregnancy. After the focus group leaders explained the method's mechanism of action, women said they preferred it to oral contraceptives because the former seemed easier to use and posed less risk of forgetting; they also felt that a single-dose regimen was less likely to cause serious side effects than the daily pill. In addition, they liked the discreet nature of the method. The authors suggest that because many women do not use regular contraceptive methods—whether because of perceived impracticality or concerns about long-term side effects—ad hoc postcoital use of the emergency contraceptive pill might meet their needs.

A full range of modern methods is available in Kenya, but nearly one in five women who want to avoid pregnancy are not currently using a method. With many such women citing fear of the perceived side effects of hormonal methods as their reason for nonuse, a fertility awareness method could fill a gap in the contraceptive method mix. In a three-month pilot study designed to assess the introduction of the CycleBeads mobile app, a digital platform for the Standard Days Method, Victoria Shelus and colleagues found that most women who had downloaded the app used it to track their period or prevent pregnancy. The reason most commonly given for choosing the Standard Days Method was fear of side effects from hormonal methods. Among those using it to prevent pregnancy, 42% had never before used a contraceptive method. By the midpoint of the study, all participants knew when fertile days occurred, and they reported high rates of condom use, abstinence and withdrawal on those days. The authors conclude that the CycleBeads app provides an alternative means of fertility control to Kenyan women who are wary of hormonal methods.

—The Editors