What does the level of service use indicate about family planning and maternal and child health programs? One might assume that widespread use of services is strong evidence that a program is doing a good job of offering wanted services, training and supervising providers and promoting its services to the public. Two articles in this issue of International Family Planning Perspectives, however, suggest that this is not always the case.
In the lead article, Jennifer Barrett and Cynthia Buckley examine patterns of contraceptive use in Uzbekistan, a country with a very strong national program [page 50] and a history of having relied on abortion for fertility control during the Soviet era. Some 60% of sexually active women of reproductive age were using a modern contraceptive method in 2002, with more than 85% of users relying on the IUD. According to multivariate analyses, women with higher material well-being, those with a university education and those who had worked outside the home in the previous year were more likely than other women to know of modern methods other than the IUD. Urban residence, higher material well-being and university education were associated with having ever used a method other than the IUD. Given programmatic constraints and strong encouragement from providers to adopt the IUD, the authors conclude, women with lower socioeconomic status and less education may be less successful than better-off women in learning about, choosing and obtaining another method.
In South Africa, where hormonal contraceptives are available free of charge at all public clinics, 61% of sexually active women of reproductive age rely on a modern method—with injectables accounting for about half of all use. Nevertheless, more than half of all pregnancies are either unplanned or unwanted. One reason often cited is the high discontinuation rate among injectable users. However, according to research in Eastern and Western Cape provinces by Joy Noel Baumgartner and colleagues, many women who discontinue injectable contraceptives do not do so intentionally [see article]. In both provinces, the great majority of continuing injectable clients arrived either on time for their scheduled reinjection or within the two-week "grace period" during which a reinjection can be given without ruling out pregnancy. In Western Cape, virtually all of these women received a reinjection. In Eastern Cape, 96% of women who arrived on time received a reinjection, but that proportion fell to 64% among those who arrived during the grace period. Of the Eastern Cape clients who were late and did not receive a reinjection, 64% were not given another method. The authors recommend that, given the rising use of injectables, providers receive refresher training on guidelines for reinjection and that users be given counseling on the need for timely reinjection and the window for reinjection. Above all, they say, women who arrive past the grace period but want to continue using an injectable must be supplied with another method to protect them against pregnancy until they are eligible for reinjection.
Also in This Issue
According to data from a national survey analyzed by Aleksandar Stulhofer and colleagues [see article], risky sexual behaviors are common among young people in Croatia. One-third of sexually experienced 18–24-year-olds had had two or more partners in the past year, and a similar proportion had had at least one one-night stand during that period. Nevertheless, only half reported having used a condom the last time they had sex, and about one in five had always used a condom during sex over the last 12 months. For both men and women, positive attitudes toward condoms and condom use at first intercourse were the strongest predictors of consistent condom use over the last 12 months. These findings, the authors argue, indicate the importance of providing comprehensive sex education before young people become sexually active.
Reducing maternal mortality and improving maternal health have been central policy goals in Bangladesh for the last 15 years. Nevertheless, data from the 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey indicate that during the three years before the survey, only four in 10 pregnant women sought prenatal care from a qualified provider, and one in seven did so during the first trimester. Twelve percent of births were delivered by a medically trained provider. Complications occurred in 61% of pregnancies, yet women's recognition of life-threatening complications was low and relatively small proportions sought care. Although convulsions and excessive bleeding account for more than half of all maternal deaths in Bangladesh, only 26% and 18% of women, respectively, cited them as life threatening. Of women with these conditions who recognized them as life threatening, only 77% and 65%, respectively, sought treatment. The most common reason cited for not seeking treatment was cost.
Since the creation of the Demographic and Health Survey Wealth Index in 2004, investigators have used the index to measure correlations between wealth and diverse social and health outcomes, including HIV infection. However, in a Viewpoint, Jeffrey Bingenheimer argues that the index may actually measure involvement in the modern cash economy rather than wealth per se because it gives greater weight to household possessions than to traditional forms of wealth, such as land, cattle and control over human labor [see article]. In that case, he asserts, the conclusion that wealth fuels the spread of HIV in Sub-Saharan Africa may be misleading.