Abstract: A 1997-98 multimedia campaign promoted sexual responsibility among young people in Zimbabwe while strengthening their access to reproductive health services by training providers. Baseline and follow-up surveys each involving approximately 1400 women and men aged 10-24 were conducted in 5 campaign and 2 comparison sites. Logistic regression analyses were conducted to assess exposure to the campaign and its impact on young peoples reproductive health knowledge and discussion safer sexual behaviors and use of services. The campaign reached 97% of the youth audience. Awareness of contraceptive methods increased in campaign areas but general reproductive health knowledge changed little. As a result of the campaign 80% of the respondents had discussions about reproductive health--with friends (72%) siblings (49%) parents (44%) teachers (34%) or partners (28%). In response to the campaign young people in campaign areas were 2.5 times as likely as those in comparison sites to report saying no to sex 4.7 times as likely to visit a health center and 14.0 times as likely to visit a youth center. Contraceptive use at last sex rose significantly in campaign areas (from 56% to 67%). Launch events leaflets and dramas were the most influential campaign components. The more components respondents were exposed to the more likely were to take action in response. A multimedia approach increases the reach and impact of reproductive health interventions directed to young people. Building community support for behavior change also is essential to ensure that young people find approval for their actions and have access to services. (authors)

Abstract: Interviews were conducted in squatter settlements in Karachi Pakistan with Muslim women 30 years old or younger their husbands and their mothers-in-law to explore factors that influence couples contraceptive use. Univariate and multivariate regression analyses were conducted to examine the associations between contraceptive use and several variables including social and demographic characteristics; religious beliefs; communication about family planning (FP) among the three family members; womens mobility and decision-making capability; acceptance of information about FP in the mass media; and exposure to FP messages from health care workers. Univariate analyses indicate that women who reported using modern contraceptive methods were significantly more likely to be literate (odds ratio 1.7) to be exposed to an urban environment (1.8) and to have had at least 5 live births (2.0). According to multivariate analyses women who were literate who were of high economic status whose mother-in-law reported discussing FP with them and who had received FP messages from health care workers were two-three times as likely to use contraceptives as were other women. In addition women who said it was appropriate for FP messages to be delivered through mass media were 50% more likely to use contraceptives. The long-term goals of improving womens education levels and economic status are important for increasing contraceptive prevalence in Pakistan. At the same time policy-makers should initiate short-term interventions such as engaging religious leaders in FP programs encouraging the outreach efforts of community health care workers and targeting mothers-in-law with FP messages as these are likely to be effective in increasing womens contraceptive use. (authors)

Abstract: In countries such as Ghana where the law restricts elective induced abortion data to quantify the incidence of abortion are scarce. Existing data on induced abortions in Ghana come mainly from hospital records which are unreliable because record-keeping is poor and induced abortions often are classified inaccurately. A multistage random sampling design was used to identify 18301 women aged 15-49 from eight communities in four of the 10 regions in Ghana between January and March 1997. Of the identified women 1689 were pregnant. From March 1997 to March 1998 fieldworkers living in the pregnant womens communities monitored their health and pregnancy outcomes including self-induced abortions. During the study period the rate of abortion in the study areas was 17 induced abortions per 1000 women of childbearing age. There were 19 abortions per 100 pregnancies (or 27 abortions for every 100 live births). The majority (60%) of women who had an abortion were younger than 30 and 36% were nulliparous. 45% had obtained their abortions before the 7th week of gestation and 90% had done so before the 10th week. Only 12% of the women said they had obtained their abortion from a physician. Muslim women had decreased odds of obtaining abortion. Women who lived in urban areas who were educated or who had four or more children had increased odds of obtaining an abortion. Women who were self-employed had greater odds of obtaining an abortion than those who were employed by someone else. Ghanas abortion law does nothing to prevent many induced abortions from occurring. However few Ghanaian women who seek abortions obtain them from physicians and most appear to induce abortions themselves often in collaboration with pharmacists. (authors)

Abstract: Understanding family planning practices is fundamental to designing training supervision and logistic systems that maximize clients access and quality of care. It has not always been clear however why providers impose inappropriate restrictions on clients or perform medically unnecessary procedures. Situation analysis data from Ghana were used to identify 46 facilities offering family planning services where clients were at risk of facing medical barriers and other obstacles. Interviewers visited a purposive sample of 97 providers in late 1994 and used closed- and open-ended questions to identify restrictive practices and probe providers about their reasons for these practices. Providers enforced a variety of restrictions known to impede clients access to services. Concerns about client safety and morals were the most often cited rationales for restricting services according to age and parity. Many providers were especially concerned that contraceptives might cause future fertility problems and used minimum age or parity requirements to ensure that only women of proven fertility could obtain contraceptives. A number of providers apparently believed in particular that injectable contraceptives cause permanent infertility. Providers also cited health concerns as the reason for enforcing strict resupply and revisit schedules as well as for routinely conducting laboratory tests. While protecting clients health is an admirable goal providers who lack technical knowledge of contraception may exaggerate the dangers of various methods. In seeking to impose their personal morals on clients providers violate basic client rights. (authors)

Abstract: Data from the Matlab Demographic Surveillance System were used to investigate the effects of son preference on contraceptive use abortion and fertility and trends in these effects over time in the Matlab maternal and child health and family planning project area and in a comparison area. A modified Arnold Index was used to estimate the increase or decrease in contraceptive prevalence abortion or fertility that would occur in the population in the absence of sex preference. The level of sex-selective abortion was measured by the deviation from the expected ratio of males to females at birth. Between the early 1980s and the middle 1990s contraceptive use and recourse to abortion increased in Matlab while fertility declined. Method use rose with parity in the project area. (Adequate data were not available for the comparison area). At low parities method use increased with the number of sons; among women with 3 or more children however it stabilized or decreased among those who had at least 2 sons. In the absence of sex preference contraceptive use in the project area would have risen by 9% in 1983 by 8% in 1988 and by 6% in 1993. The abortion ratio increased with parity; within parities it was generally lowest for women with no sons and was often highest for those with at least 2 sons and a daughter. In the absence of sex preference the abortion ratio would have increased by 27% in 1982-86 by 36% in 1987-91 and by 55% in 1992-95 in the project area and by 36% 37% and 38% respectively in the comparison area. The percentage of women giving birth declined as parity rose and within parities was highest for women without sons. Among women with more than 2 children fertility was lowest for those who had sons and a daughter. In the absence of sex preference fertility would have decreased by 9% in 1984-86 by 10% in 1989-91 and by 12% in 1994-95 in the project area and by 7% 8% and 9% respectively in the comparison area. There was no evidence of sex-selective abortion in Matlab. Sex preference does not have a strong effect on contraceptive use in Matlab. Its absence however would probably increase recourse to abortion which is used to limit fertility once couples have the number of sons they desire. The effect of sex preference on childbearing is becoming stronger as fertility declines because couples must achieve their desired number of sons within a smaller overall number of children. (authors)

Abstract: A representative sample of 1696 Malian adolescents (775 males and 921 females) aged 15-19 were interviewed in 1998 about sexual behavior and knowledge. 30 focus-group discussions provided complementary insights into the context of and reasons for adolescents first sexual encounters. Nearly half of sexually experienced urban males said they would have preferred to delay their first intercourse compared with about one-fifth of females and of rural males. Males most often said curiosity and peer pressure (including pressure from their girlfriends) had led them to begin having sex earlier than they would have liked while females in urban areas cited love and those in rural areas cited a promise of marriage. Focus groups however suggested that young urban women often had sex to obtain cash to meet their material needs and desires. Unmarried urban females who exhibited high self-esteem and an internal locus of control were significantly more likely to be satisfied with the timing of their first sexual encounter; these factors had no effect among males. Among adolescents who were satisfied with the timing of their first sexual experience both males and females were more likely to have ever used a modern contraceptive at first intercourse and females were more likely to have ever used a modern method. Multivariate analyses however indicated that a large part of the effect among females was mediated by psychological factors: High self-esteem and an internal locus of control were associated with an increased likelihood of having ever used contraceptives. Among young men ever-use was strongly associated with self-esteem and was only weakly associated with the timing of first intercourse. In Mali young womens psychological characteristics are strongly associated with their sexual experience (including the timing of their first sexual encounter) and ultimately with their ability to protect themselves from sexual health risks. (authors)

Abstract: With the explosive nature of the South African AIDS epidemic there is an urgent need for HIV prevention methods controlled by women. Because several microbicide trials are going on in South Africa and elsewhere there also is an urgent need to determine South African mens perceptions of and preferences for a potential vaginal microbicide. 243 men were recruited from three sites in South Africa: sexually transmitted disease (STD) clinics (N = 95) the general population (N = 98) and universities (N = 50). A brief demonstration of a potential vaginal gel microbicide was followed by a private interview which included questions about mens demographic characteristics sexual activities condom use and willingness to support their partners use of a vaginal product. The mean ages of men from STD clinics the general population and universities were 30 28 and 23 years respectively. 45% of men from STD clinics 69% from the general population and 65% of the university students reported a dislike for male condoms. More than 80% of the entire sample wanted their partner to be protected against HIV and other STDs. The majority of the men in the three groups (77-87%) would like their partner to use a microbicide and 66-82% said they would like to be involved in the decision to use a microbicide. Men were more likely to prefer a vaginal product that prevents HIV and STD transmission and does not act as a contraceptive that one that acts only as a contraceptive. The majority (58-67%) of men reported that excess lubrication was not a desired product characteristic. Vaginal microbicides may be acceptable to South African men. The amount of lubrication provided by the product and non-interference with sexual pleasure may be keys to product acceptability. Preference for an effective non-contraceptive microbicide was greater than for a contraceptive product. (authors)

Abstract: The cultural determinants of contraceptive choice are usually poorly measured and the mechanisms through which they operate to influence individual behavior are often inadequately understood. Data from a 1994 household survey in 51 villages in Nang Rong a rural district in northeastern Thailand and a village survey in all villages in the district were used to examine the effects kinship networks on womens contraceptive choice and the mechanisms through which kinship networks affect contraceptive choice. Multinomial regression analysis was conducted on a sample of 1563 non-sterilized non-pregnant women aged 18-35 who had been married 10 years or less and microsimulations were performed to illustrate the results of varying numbers and types of kinship ties on contraceptive use levels. Extended kinship ties affect contraceptive choice. The more external kinship ties households have the more likely women in those households are to use modern forms of temporary contraception. For example if all households in a village had no kinship ties with other households in the village 35% of women would use the injectable and 33% no method; in contrast if all households had 5 extended kinship ties with other households in the village 41% of women would use the injectable and 25% no method. Extended kinship ties outside the village also affect contraceptive use: If all households had only two extended kinship ties outside the village 28% would use the pill 36% the injectable and 33% no method whereas if all households had 8 such ties 33% would use the pill 38% the injectable and 27% no method. Village-level patterns of extended kinship ties also affect contraceptive choice. If all villages were to average just 1 extended kinship tie outside the village per household 23% of women would use the pill 26% the injectable and 43% no method while if all villages averaged 3 such ties per household 31% of women would use the pill 38% the injectable and just 28% no method. Kinship ties at both the household and the village level affect contraceptive choice. Policymakers and program planners should be aware of the effects of patterns of migration and subsequent networks of extended kin on the distribution of information about and the acceptance of modern forms of contraception. (authors)

Abstract: In a survey on reproductive health approximately 1000 ever-married Sudanese women were randomly selected in each of three areas--Haj-Yousif and Shendi in the north where female circumcision is widely practiced and Juba in the south where it is relatively rare. Interviewers collected data on the prevalence of the three types of circumcision their social and demographic correlates womens attitudes toward the practice and their perception of their husbands attitudes. Some 87% of respondents in Haj-Yousif almost 100% of those in Shendi and 7% of those in Juba have been circumcised. Pharaonic circumcision -- the most severe type -- was reported by 96% of circumcised women in Shendi and 69% of those in Haj-Yousif but only 31% of those in Juba. However a small but significant shift from Pharaonic to Sunna circumcision appears to have occurred in Shendi and Haj-Yousif in recent years. Overall 67% of respondents in Haj-Yousif 56% of those in Shendi and 4% of those in Juba support continuation of the practice; more highly educated and economically better off women are less likely to be supportive in the two high-prevalence areas. Social custom is the most commonly cited reason for favoring continuation of female circumcision in Haj-Yousif and Shendi (69-75%) while better marriage prospects are the most frequently given reason in Juba. Based on the womens perceptions men are more likely than women to favor discontinuation. Female circumcision seems to be declining slightly in some areas of Sudan. A culturally accepted policy and political commitment to eradicate the practice are needed. Education and economic empowerment of women would help lower support for the practice. A mass media campaign publicizing the risks of female circumcision and the fact that female circumcision is not obligatory for Islamic women would also be helpful. (authors)

Abstract: Time constraints have been implicated in family planning providers inability to offer comprehensive counseling to their clients. It is important for providers to know whether lengthening counseling sessions increases the amount of relevant information imparted to clients. 28 women were trained to pretend to solicit an effective method and to opt for the injectable contraceptive at 19 clinics in urban areas from a national sample of Ministry of Health facilities in Peru. Each clinic was visited on different days by 6 of these ‘simulated clients’ for a total of 114 cases. For each visit the woman recorded on a 46-item checklist the topics discussed by the provider and estimated the duration of the counseling session. Providers dedicated anywhere from 2-45 minutes to counseling. The amount of information given that was relevant to the clients choice significantly increased by 43% when the session length went from 2-8 minutes to 9-14 minutes. However further improvements in the amount of useful information exchanged were trivial and nonsignificant when session lengths extended beyond 14 minutes. At any duration many pieces of information that should have been exchanged had not been. Offering a wide range of contraceptive options took up most of the consultation time and was highly correlated with session length. Discussion of the chosen method’s side effects and screening for contraindications did not vary by session length. Counseling sessions longer than 14 minutes confer little advantage in terms of effective counseling for women who choose the injectable. It is important that providers use the available time more efficiently; that they be more practical in assessing clients’ needs; and that they avoid providing too much information about irrelevant methods. They should focus on the method chosen by the client and address that specific method in greater depth. (authors)

Abstract: Sub-Saharan Africa has a considerable unmet need for contraception. In 1998-99 the Gold Circle campaign--a regional initiative to promote and improve family planning (FP) service delivery sites--was launched in Cameroon. During the last quarter of 1999 571 women who had been interviewed during the 1998 Cameroon Demographic and Health Survey were reinterviewed regarding their exposure to the Gold Circle campaign and their perceptions on and use of contraceptives. The impact of the campaign was evaluated by assessing the panel data and by using an ideation model of behavior change. In addition service statistics from Gold Circle and non-Gold Circle FP delivery sites were contrasted to assess the effects of the campaign on clinic performance. More than one-third of the women surveyed reported exposure to the Gold Circle campaign 52% of whom mentioned being exposed to the campaign through television. Those with primary and or postprimary education were four and six times as likely respectively as those with no education to have been exposed to the campaign. Exposure was associated with a significant increase in the level of FP ideation as well as with an increased likelihood of using a modern contraceptive method (80%). The service statistics indicate that the campaign led to a significant increase in the demand for FP services at Gold Circle clinics with the number of new clients more than doubling immediately after the campaign launch. The Gold Circle campaign had appreciable success in promoting FP in Cameroon. The campaign had a considerable positive influence on both FP ideation and contraceptive use. (authors)

Abstract: Most of what is known about women seeking pregnancy termination in Nepal has been learned from women admitted to hospitals with abortion-related complications. Little is known about women who obtain "safe" abortions from trained providers. Social and demographic information was collected from women seeking induced abortions from a private clinic in Nepals capital city of Kathmandu. These data were analyzed and compared to data from 2 other sources. 36% of the women were between 25 and 29 years of age and 43% and 2 living children. 40% had more than a high school education 91% were from Kathmandu and 48% practiced contraception. The primary motivation for seeking abortion for 34% of the women was the desire for no more children. Women in urban areas who had ever had an induced abortion tended to be younger of lower parity and more educated than those in rural areas. Women in Nepal desire a small family size especially those living in urban areas. Although significant numbers of women practice contraception induced abortion is also used primarily to control family size and for birthspacing. Increased promotion and use of contraceptive methods are needed to decrease the number of abortions especially those that are high-risk and unsafe. (authors)

Abstract: In Turkey the inadequacy of family planning services leads many women to have repeat abortions which constitutes a major public health issue. In response the postabortion family planning program established linkages between abortion and family planning services. This paper reviews a decade of experience in postabortion family planning services which were delivered through three related phases: 1) a pilot program in a single public maternity hospital 2) an expansion of the program into 10 public facilities and 3) further expansion into 12 private-sector and two public-sector hospitals in Istanbul. Overall the experience in Turkey shows that women turn to abortion because of lack of contraception options. In an analysis of abortion trends it is noted that the postabortion family planning program efforts implemented throughout the 1990s contributed to the decline in abortion both by increasing the use of contraceptives among women who had had an abortion and by tilting the method mix toward more effective methods. The commitment of decision-makers was a particularly important criterion in the success of postabortion interventions. At the national level the program required support from management at the Ministry of Health and at the Social Insurance Organization. The most important challenge for the postabortion family planning program in Turkey was reaching the private sector.

Abstract: Information on adults attitudes toward adolescent sexual and contraceptive behavior is crucial since adults may facilitate or obstruct adolescents adoption of healthy behaviors. Relatively little information in this area has been gathered in sub-Saharan Africa. In 1998 baseline data were collected from 1027 adults aged 30 and older as part of an evaluation of a youth center in Lome Togo. Chi-squares tests and multivariate analyses were used to assess differences by gender in adults perspectives on adolescent reproductive health behaviors. Women in Lome hold more conservative attitudes than men toward adolescent sexuality specifically in their views on contraceptive use among adolescents and unmarried couples. For example bivariate data indicate that 58% of adult women but only 48% of adult men disapprove of premarital sex among adolescents. Moreover nearly one-half (48%) of women disapprove of young people using contraceptives compared with fewer than one-third (31%) of men; on the other hand 40% of women and 25% of men disapprove of unmarried couples practicing contraception. According to multivariate analyses older and less-educated adults are more likely to hold conservative attitudes than younger and more-educated adults. Once age and other social and demographic variables are controlled for women are significantly more likely than men to have held a reproductive health discussion with a daughter but there is no difference by gender of the adult in the likelihood of having had such a discussion with a son. Womens comparatively more conservative attitudes may be important if women are young peoples primary source of reproductive health information. Future research needs to examine whether these adult perspectives directly affect adolescent reproductive health outcomes. (authors)

Abstract: Using data from the longitudinal surveillance systems of the Operations Research Project of the International Center for Diarrheal Disease Research Bangladesh a before-and-after analysis of the contraceptive prevalence method mix source mix new acceptance rate and dropout rate was conducted to assess the consequences of the shift in service delivery approach. The shift from domiciliary distribution to clinic-based service delivery appears to have resulted in a slight increase in contraceptive prevalence in the urban study area from 54-56% before the shift to 55-57% afterward. The changeover did not produce any discernable variation in the method mix the proportion of new acceptors of family planning or the contraceptive dropout rate. This apparent lack of change can be explained by increased use of alternative sources with a substantial rise among users in reliance on pharmacies and shops (30-35% before vs. 42-50% after). In two rural study areas the shift from domiciliary distribution to service delivery from static sites known as cluster spots resulted in an increase in the prevalence rate from 52% to 57% in Paira and from 40% to 45-46% in Durgapur. The changeover coincided with greater use of injectable contraceptives and decreased reliance on traditional methods among rural contraceptive users. A notable immediate increase in new acceptors also was evident as was a long-term decline in dropouts. In Paira following the shift 43-44% of current users obtained their contraceptive supplies from cluster spots as did 32-33% in Durgapur. The recent change in the family planning program toward clinic-based delivery of an integrated package of essential health and family planning services appears likely to maintain and perhaps even increase contraceptive prevalence levels in Bangladesh. (authors)

Abstract: Context: In Orissa, one of the most impoverished states in India, reproductive health is poor, and the use of condoms and other reversible contraceptives is uncommon. To promote condom use, it is important to know who is using condoms, whether condoms are used for pregnancy or disease prevention and how much potential for use exists in a community. Methods: A cross- sectional population-based survey carried out in 1998 in the four coastal districts of Orissa among 2,087 men aged 18-35 collected data on fertility preferences, sexual behavior and condom use. Levels of use and need for condoms were estimated separately for sexual activity within and outside marriage. Aggregate levels of use and need were derived by applying individual-level estimates to the male population. Results: Ninety percent of all condoms were used for sex within marriage (44% for spacing and 46% for limiting births). Condoms were used during 3% of marital sex acts and 15% of nonmarital sex acts. Two-thirds of the unmet need for condoms is for premarital or extramarital sex (53% and 13%, respectively). Given the current method mix, men in Orissa have an unmet need for 2.3 million condoms annually, but if users of traditional methods were encouraged to switch to modem methods, that total would reach 4.4 million. Conclusions: Condoms should be promoted differently among different target groups: as an effective way to prevent HIV and other sexually transmitted diseases among the minority of men who engage in high-risk sexual behavior, as a means of preventing both pregnancy and disease among young unmarried men and as a spacing method among married couples.

Abstract: Most research on abortion in Latin America has focused on women who are hospitalized with abortion complications but little is known about the characteristics of women who are able to obtain clandestine procedures performed by trained personnel working in sanitary conditions. Analysis of medical records for 808 clients of an urban clandestine abortion service in South America was supplemented with observation of clinic operations for 6 weeks in 1995. Nearly 9 in 10 clients had at least a secondary education about three-quarters were younger than 30 and a similar proportion were unmarried. 54% had never given birth and 13% had had at least 1 prior abortion. Three-fifths of women had not been using a contraceptive method when they conceived; among users three-fifths had been using a traditional method. 3% experienced mild complications related to the procedure (e.g. heavy bleeding or pelvic pain) and another 2% reported serious complications (e.g. pelvic infection hemorrhage or suspected uterine perforation). To reduce the need for abortion it is important for family planning programs to include women who are young unmarried and highly educated in their outreach efforts. (authors)

Abstract: A new initiative in Bangladesh has shifted the emphasis in service delivery from door-to-door contraceptive distribution to delivery of a broader package of essential services primarily through clinics. If the revised approaches are to result in more cost- effective services and better reproductive health clients will need to take more initiative and bear more costs and providers will have to become more responsive to clients priorities. In- depth semi-structured interviews group interviews and observations in service delivery settings were conducted in three rural and two urban sites to examine how clients communities and program staff were adapting to the new service delivery norms. The analyses in this article draw from about 125 interview transcripts. Community reactions to the service delivery changes generally have been favorable and suggest that family planning (FP) clients and their families are willing to adapt to the new approaches. However responses to the policy changes on the part of clients and communities appear to be shaped by norms that developed under the previous FP program model. Increased charges for services appear to have exacerbated peoples confusion and resentment over payments for services and the right of clients to receive free care. Moreover providers and clients seem to find it difficult to shed habits and assumptions surrounding the provision of specific methods with some providers still feeling that women need to be motivated to practice FP and with some clients fearing that providers will try to induce them to use certain methods. Clients also often feel that since service providers furnished them with a method these providers should bear some responsibility for treating their health problems or side effects free of charge. And some have come to expect not only discounted or free services but also compensation for adopting clinical methods. Fear and suspicion of clinical methods--and of providers reasons for offering them--persist although perhaps to a lesser extent than was the case before the service delivery model was changed. Lingering ideas about entitlements the role of government and the agenda of the national FP program create obstacles for nongovernmental organizations as they try to build a sustainable network of family health services in Bangladesh that is both client-focused and effective in terms of its public health impact. The new policies need to be persistently reinforced throughout the service delivery system. In addition providers need to translate and communicate policy changes to make them more comprehensible in the communities affected by them. (authors)

Abstract: In 1998 a survey was conducted as part of an evaluation of Perus national sexuality education program which was launched in 1996. In all 6962 students from 38 schools participated respondents completed a questionnaire that explored knowledge and attitudes towards sex covered in the program as well as their background and psychosocial characteristics. The study used bivariate analyses to identify factors affecting the students sexual behavior and condom use. Overall 5% of respondents had had intercourse prior to the survey. The students perceptions of their peers’ sexual activity are one of the most consistent predictors of their own behavior. Another determining factor of sexual behavior identified is self-esteem. Although most background characteristics were not associated with sexual behavior respondents of high socioeconomic status were less likely to be sexually experienced compared to those in the lowest stratum. Similarly socioeconomic status self-esteem and perceptions of peer behavior influenced condom use.

Abstract: According to an analysis of data from partner relations surveys of men in Cote dIvoire Tanzania Thailand and in Lusaka Zambia men who have many sexual partners before marriage are more likely to engage in extramarital intercourse. The surveys were conducted in 1989 and 1990 by the Global Program on AIDS in which all respondents were asked about premarital and extramarital sexual experience current living arrangements and social and demographic characteristics. Overall analysis indicated that mens premarital sexual behaviors are linked to the likelihood that they will have extramarital intercourse but those relationships vary across countries. 5 predictive factors associated with extramarital sex were identified: age at first intercourse length of acquaintance with the first partner before intercourse time between sexual debut and marriage whether men married their first partner and number of premarital partners. In conclusion the investigators suggest that early sexual initiation and multiple premarital partners may establish a pattern of sexual conduct that persists into later sexual lifestyle patterns.

Abstract: Adolescent women in Maputo Mozambique have a high risk of death from pregnancy-related causes and the great majority of such deaths are avoidable. Overall 52 adolescents died of pregnancy-related causes at Maputo Central Hospital between 1989 and 1993 for a rate of 387 deaths per 100000 live births compared with a ratio of 294 per 100000 among older women. Although adolescents were 30% more likely than older women to die of maternal causes prenatal records indicate that adolescents who died were significantly less likely than others to have been classified as being at high risk (2% vs. 21%). Of the 19 risk factors listed on prenatal cards at the hospital only 5 were identified among pregnant adolescents. The investigators note that the low number of risk factors identified on the cards of adolescents who later died suggests that the screening program at the hospital is not sufficiently sensitive. Estimating that 8 of 10 maternal deaths at the hospital could have been prevented they conclude that "recognizing the existence of avoidable factors in the majority of maternal deaths must be the first step...in designing and implementing reproductive health care programs adequate for young people." (full text)

Abstract: Family planning (FP) clinics that plan to add sexually transmitted infection (STI) services should consider alternatives to modified WHO risk-inclusive algorithms for identifying infected women. A sample of 767 FP clients from Kingston Jamaica were interviewed and examined and specimens were obtained to detect the agents that cause gonorrhea chlamydia and trichomoniasis. Serum was tested to detect the bacteria that cause syphilis. Decision models for classifying women with STI were compared using clinical statistical criteria. Models included STI classifications based on the weighted sum of STI risk factors on the presence of two or more factors identified via an interview or on an interview augmented with a urine dipstick test (i.e. rapid risk assessment). These models were compared with a modified WHO algorithm originally intended for STI clients in Jamaica. Individual factors associated with gonorrhea chlamydia and trichomoniasis were urine leukocyte esterase dipstick test outcomes >1+ (indicating the likelihood of infection based on the concentration of white blood cell enzymes on a scale of negative trace 1+ 2+ and 3+) multiple partners in the past year friable cervix and age <25 years. An additional risk factor for cervical infection alone (gonorrhea or chlamydia) was spotting after sex. Reported vaginal discharge was not significantly associated with infection. For cervical infection the WHO risk-inclusive algorithm was least accurate (a positive predictive value of 14%) the weighted-risk algorithms were best (a positive predictive value of 23%) while the interview-alone and the rapid risk assessment were slightly less accurate (positive predictive values of 20%). The modified WHO risk-inclusive algorithm appeared inappropriate for asymptomatic women. The rapid risk assessment was easier to perform and more predictive. Urine leukocyte esterase dipstick tests may be useful when pelvic examinations are not feasible. The STI assessment models other than the WHO algorithm should be evaluated in other settings where STI prevalence is high or where patients are unlikely to seek further evaluation to better identify women in need of counseling further evaluation or treatment. (authors)

Abstract: The data analysis of the AIDS prevention study conducted in 1994-1998 gathered information from more than 15000 men and women aged 15-59 in rural Rakai Uganda. At follow-up visits every 10 months participants were asked to provide blood and urine samples and women were asked for a self-collected vaginal swab; all samples were tested for HIV and a variety of other sexually transmitted diseases. The participants also completed interviews in which they were asked about their background characteristics and sexual behavior. Couples in which one partner had been HIV-positive and the other is HIV-negative at enrollment were identified and the probability of infection assessed. Results note that on average each time a monogamous heterosexual couple in which one partner is HIV-positive has intercourse the probability that the virus will be transmitted to the uninfected partner is 0.11%. This probability rises significantly as the infected partners viral load increases and it is elevated if the HIV-positive partner has genital ulcers. In view of this perspective it is suggested that interventions aimed at lowering viral load could reduce transmission.

Abstract: Researchers analyzed data from 540 sex workers in Nairobi Kenya who were screened to determine whether an association exists between vaginal douching and sexually transmitted infections. 30% of the women screened tested positive for HIV while 49% tested positive for bacterial vaginosis 16% for trichomoniasis 10% for candidiasis 10% for gonorrhea 6% for syphilis and 1% for genital ulcers. 72% of the women surveyed reported having practiced vaginal douching. Researchers found a significant relationship between douching and condom use. Women who practiced vaginal douching were more likely than those who did not to have ever engaged in anal sex. They also had more sexual partners per day. A significantly higher incidence of bacterial vaginosis was found among the female sex workers who douched. The researchers did not find a significant association between douching and HIV infection however a result that the researchers attribute to greater condom use among sex workers who douche.

Abstract: This study determined the relative acceptability of available contraceptive methods among 8077 women who sought contraceptive services at one of 10 research centers at medical colleges around India during the 1-year study period. These women discussed the implant the Copper T 200 IUD combined oral contraceptive pills condoms vasectomy and tubal sterilization with their health care provider including each methods benefits and liabilities. Data were gathered on demographic characteristics obstetric history and choice of contraceptive. Overall findings showed that the womens contraceptive choices frequently differed from the recommendations of their health care providers. However differences of opinion with the health care provider did not deter the women from selecting the contraceptive method that they felt best suited their particular needs. In addition it is noted that the great majority of the women were able to make an informed contraceptive choice after receiving balanced information about their options. It is concluded that there is an urgent need for a reorientation-training program to promote the concept and practice of informed choice in the national program.

Abstract: According to findings from a multicenter study personalized voluntary HIV counseling and testing can reduce risk behaviors among men and women in developing countries. The effectiveness study was conducted at clinics in Kenya Tanzania and Trinidad in 1995-98 with a total of 3120 individuals and 586 couples enrolled. Participants were randomly assigned to receive either personalized counseling and testing or a group education intervention. Follow-up interviews indicated that the proportion of participants who had unprotected intercourse with someone other than a primary partner dropped by about 35-39% among men and women receiving individualized services but by only 17% among those receiving group education. It is noted that patterns of behavior change differed by participants HIV infection status. In a related analysis researchers assessed the cost-effectiveness of providing voluntary HIV counseling and testing in Kenya and Tanzania. Results demonstrate the voluntary counseling and testing is highly cost-effective particularly when offered to couples and to HIV-infected people.

Abstract: This article discusses the role of Thai husbands as vectors of human papillomavirus (HPV) transmission from prostitutes. Infection with HPV type 16 or 18 among Thai women is the most important factor in the progression of precancerous cervical lesions to invasive cancer. This finding was confirmed from three interrelated studies conducted--two involving women with cervical cancer and one involving commercial sex workers in Bangkok and husbands of a subgroup of women with cervical cancer and controls from the first two studies. The results showed that the great majority of women with cervical cancer had intercourse only with their husbands and their risk of cancer is strongly related to the frequency of their husbands visits to prostitutes as young men; according to investigators most are therefore likely to have acquired carcinogenic types of HPV from their husbands.

Abstract: A prospective study was conducted in England and Scotland to investigate the relationship between IUD use and subsequent fertility among nulliparous women. Data from 558 women who had stopped using an oral contraceptive IUD or barrier method in order to conceive were analyzed. Multivariate analysis was used to assess the independent effects of contraceptive method use maternal age social class smoking history and history of gynecologic and other illnesses on fertility. Overall findings note that women who have never given birth and have used an IUD for an extended period of time face decreased fertility when they try to conceive. In contrast women who had been using barrier method achieved conception most quickly after discontinuation of contraceptive. Duration of oral contraceptive use had no impact on fertility. It is also indicated that the long-term use of IUD by a nulliparous woman increases the risk of impairment of fertility to clinically important extent. Moreover older maternal age lower social class and history of gynecologic and other diseases were associated with fertility decline.

Abstract: This article presents the results of the 1998-99 National Family Health Survey-2 conducted among a sample of respondents in India whose population crossed the 1 billion mark in May 2000. The survey provides data on castes tribes or classes the government has designated as socially and economically deserving of protection. Information is given on the topics of marriage fertility and fertility preferences contraceptive knowledge and use maternal and child health sexual and reproductive health and domestic violence. A notable finding is that women in India can expect to have nearly three births if existing rates of fertility continue. However if women had only wanted births the total fertility rate would drop by 25% to replacement level (2.1 lifetime births). Evidence indicates that while nearly half of currently married women 15-49 years old practice contraception. Female sterilization predominates accounting for 71% of all use.