In many developing countries, men are the dominant partner in their relationships, and often make the decisions about whether and when to have sex, whether to use a contraceptive and how many children to have. Cultural beliefs often have a strong influence on these decisions. The first two articles in this issue of International Family Planning Perspectives examine situations in which such underlying influences have important implications for efforts to lower levels of fertility and protect women's sexual and reproductive health.
Many Asian countries have a strong cultural preference for sons, which sometimes conflicts with the growing desire for smaller families. Nepal, where fertility has declined from 6.3 births per woman in 1976 to 4.1 in 2001, is no exception. According to data from the 2001 Demographic and Health Survey, although 70% of Nepalese men with at least one living child did not want to add to their families, only 42% of these men were using a permanent method of contraception and 24% were using no method at all. Analyses by Govinda P. Dahal and colleagues suggest that son preference is key: The probability of relying on male or female sterilization was highest among men who had at least two living sons and lowest among those who had only daughters, while the probability of using no method was highest among those who had only daughters [see article]. Although the Nepalese government has set a goal of reaching replacement-level fertility by 2017, it is unlikely to achieve its aims if even men who desire smaller families delay use of permanent methods until they have two sons.
Alcohol consumption has often been linked to risky sexual behavior, but it is unclear whether the link is mediated by expectations about the effect of alcohol on sexual performance. Juan Antonio Galvez- Buccollini and colleagues examine this issue using data from a survey of men aged 18–30 living in a shantytown in Lima, Peru [see article]. Overall, 36% of the men said they had consumed five or more drinks in a row at least once a month for the past 12 months and were classified as heavy episodic drinkers. In addition, 56% agreed with at least one of seven statements about the effects on alcohol on sexual performance (e.g., "I enjoy having sex more if I have had some alcohol," "Women can have orgasms more easily if they have been drinking," and "I feel more masculine after a few drinks"). In analyses that controlled for age, marital status, education and heavy episodic drinking, beliefs about the effects of alcohol on sexual performance were associated with having had multiple partners in the past year, not having used a condom at last sex and not having used a condom at last sex with a casual partner. In a culture where these beliefs are widespread, their association with multiple partners and lack of condom use place men's wives and regular partners at high risk.
Also in This Issue
• Khatuna Doliashvili and Cynthia J. Buckley use data from the 1999 Georgia Reproductive Health Survey compare reproductive health risks among women forced to migrate from their homes to the risks among those in the general population [see article]. In analyses that controlled for behavioral factors only, internal displacement was associated with having ever received a diagnosis of pelvic inflammatory disease (a relationship that lost significance after the addition of socioeconomic variables), but not with having received an STI diagnosis. Having had a gynecological examination in the past year and having received a previous STI diagnosis were associated with PID diagnosis among both displaced and nondisplaced women; however, living in the capital and speaking a minority language at home were associated with reduced risks of PID only among nondisplaced women.
• In Nepal, girls have traditionally been married at a very young age, with cohabitation often beginning several years later. Using data from the 2001 Demographic and Health Survey, Marcantonio Caltabiano and Maria Castiglione show that, for women married before age 20, the marriage celebration has occurred later over the past several decades and the period between the marriage celebration and spousal cohabitation has decreased [see article]. For Nepalese men married before age 25, the timing of these events remained relatively stable. In analyses that accounted for the effects of individual and couple characteristics, younger age at interview was associated with higher odds of simultaneous marriage and cohabitation for both males and females, and with higher odds of premarital sex for males.
• In Nigeria, where abortion is legal only to save a woman's life, estimates place the annual number of abortions at more than 600,000 and the number of women treated for abortion complications each year at 142,000. In a 2002–2003 survey at hospitals in eight states in Nigeria, 2,093 patients were identified as having come to the hospital seeking care related to pregnancy loss. According to analyses by Stanley Henshaw and colleagues, 36% of these women had attempted to end their pregnancy before coming to the hospital (24% with and 12% without serious complications), 33% came directly to the hospital to seek an abortion and 32% needed treatment for a miscarriage [see article]. Among women with serious complications from an attempted abortion outside the hospital, 2.4% died. Applying this percentage to the estimate of 142,000 women treated for complications each year, the authors calculate that nearly 3,000 women die each year from complications of induced abortion.