IN THIS ISSUE
The decision to continue or discontinue the use of a contraceptive method depends on many factors—the number and acceptability of contraceptive options, personal circumstances, and fertility desires. The complexities of this last factor—and the difficulties of measuring it—have become increasingly clear. Whether one talks about intentions, planning or a woman's emotional response to becoming pregnant, fertility desires and the strength with which they are held are likely related to whether women discontinue their method and, if so, whether they switch to another method right away. The lead article in this issue, "Contraceptive Discontinuation and Unintended Pregnancy: An Imperfect Relationship," uses DHS data from six countries to examine this relationship.
In their study, Sian Curtis and colleagues examine whether a low motivation to avoid pregnancy is associated with contraceptive discontinuation [see article]. According to their study, the proportion of live births reported as intended was 16–54% following contraceptive failure and 37–51% following discontinuation for reasons other than a desire for pregnancy (most often method-related reasons such as side effects). Moreover, in a multivariate analysis, women were less likely to report a birth as intended after contraceptive failure or discontinuation for method-related reasons if they had more children or if the pregnancy occurred after method failure rather than discontinuation. These findings suggest, the authors say, that family planning programs should focus on identifying women who strongly desire to avoid pregnancy and helping them adopt and maintain use of an appropriate contraceptive method.
Nina Ehrle and Malabika Sarker examine the knowledge and attitudes of pharmacy workers in Managua, Nicaragua, and how these factors may affect women's access to emergency contraceptive pills in a setting where abortion is illegal for any reason [see article]. According to interviews with 93 vendors, each representing one pharmacy, all were aware of emergency contraceptive pills and had experience selling them, usually without a prescription. Of the 79% of vendors who knew that the pills should be taken after unprotected intercourse, fewer than half (45%) knew that the pills can be taken up to three days afterward; none knew that they are effective up to five days afterward. Most of the pharmacy workers overestimated contraindications and side effects of the method. Sixty-five percent of vendors were willing to provide the pills to any woman in need, but only 13% would provide them to minors. The authors conclude that pharmacy personnel need additional education to perform their role as gatekeepers to emergency contraceptive pills and to the information women need to use the method successfully.
Diana Lara and colleagues also assess pharmacy vendors, but focus on their prescribing practices related to misoprostol [see article]. Using simulated clients—representing a young woman, an adult woman and an adult male partner—who visited 192 pharmacies in four regions of Mexico asking for a drug to "interrupt a pregnancy," the study found that 18% of vendors recommended misoprostol spontaneously and 60% did so after the client asked specifically for the drug. However, only 15% of vendors recommended a potentially effective dosing regimen. Vendors based in Mexico City (where abortion is legal) and those in the Central region were more likely than those in the North to sell misoprostol without a prescription. Pharmacies that were independent and those located in low-income areas were more likely than chain pharmacies and those located in medium-income areas to sell the drug by the pill rather than the bottle. According to the authors, the frequently inaccurate and incomplete information provided to clients about using misoprostol for abortion suggests the need for improved training of pharmacy vendors in medication abortion options and development of ways to provide information about the method directly to women.
In an update on levels and trends in legal abortion by Gilda Sedgh and colleagues, statistics and estimates were available for 64 of the 77 countries and major territories worldwide in which legal abortion is generally available [see article]. In the 25 countries with complete records—all of them developed countries—abortion rates for 2008 ranged from seven (in Germany and Switzerland) to 30 (in Estonia) abortions per 1,000 women of childbearing age. Between 1996 and 2008, rates declined in most of the 20 countries with consistently reliable information for the whole period, although the pace of decline slowed after 2003. The highest rates were in developing countries with incomplete records. The authors note that even in some countries with liberal abortion laws, such as India, Nepal, Cambodia, Ethiopia and South Africa, substantial numbers of abortions are unsafe, illegal, or both. In such countries, women may resort to unregistered providers because the number of approved providers is insufficient, because the services of unregistered providers may be less costly or easier to obtain or because such providers may seem to offer more privacy.
Also in This Issue
In Niger, which has the world's fastest growing population, levels of malnutrition are high, the amount of arable land is small and declining and droughts are frequent. In a Comment, Malcolm Potts and colleagues examine the problems posed by Niger's rapid population growth and the policy options proposed to confront it [see article].