In many developing countries, complications of unsafe abortion are not only an important cause of maternal mortality, but also a major burden on health care systems. This situation is particularly difficult where abortion is illegal and family planning services are not easily accessible in all parts of the country. The lead article in this issue of International Perspectives on Sexual and Reproductive Health calculates the health system costs involved in treating abortion complications, and compares them to the estimated costs—drawn from other studies—of providing all women with comprehensive family planning and safe abortion services.
Using data from Africa and Latin America (data from Asia are not available), Michael Vlassoff and colleagues developed two estimates, one based on the average total cost per patient from 20 empirical studies, and one based on the average total cost of specific components of postabortion treatment [see article]. Per-patient costs (in 2006 U.S. dollars) calculated using the first approach were $83 in Africa and $94 in Latin America, compared with $57 and $109, respectively, for the second approach. Using a variety of assumptions on such factors as severity of complications and standard of care to calculate average estimated costs for the two regions combined, the researchers found that the two approaches yielded similar totals—$274 million and $280 million, respectively. According to the authors, comparisons of these costs with the costs of contraceptive services and safe abortion drawn from other studies indicate that the latter are by far the most cost-effective approaches.
In Rwanda, the most densely populated country in Africa, continuing rapid population growth threatens the country's economic growth and political stability [see article]. Despite a sizable gap between ideal and actual family size (4.5 vs. 6.1 children), only 17% of fecund women were practicing contraception in 2005, and 58% of women desiring to stop childbearing were not using a contraceptive method. Using data from the 2005 Rwanda Demographic and Health Survey, Dieudonné Muhoza Ndaruhuye and colleagues found that negative attitudes toward contraception and lack of access to accurate family planning information were associated with unmet need. The authors recommend that interventions target negative attitudes among both women and men and that community-based family planning services be strengthened to expand provision of information and services in rural areas.
Despite the efforts of India's family planning program to widen the range of contraceptive methods available to couples, two out of three married women who practice contraception still rely on tubal sterilization. Because Indian women's contraceptive use is often decided by their husband and his family, Arundhati Char and colleagues explored men's knowledge and attitudes about family planning in two rural districts of Madhya Pradesh, one of the country's least developed states [see article]. According to survey data, 34% of the men relied on tubal sterilization for contraception; for two-thirds of this group, it was the only method they had ever used. In the focus groups, the men said they were the main contraceptive decision makers, but frequently mentioned their limited knowledge of contraception and their desire for more information. Their wives, they said, were their primary sources of information. Many men expressed concern about the effectiveness of tubal sterilization and its assumed side effects (of which weakness was the most commonly mentioned); nevertheless, few saw vasectomy as a feasible option. The authors recommend face-to-face dissemination of family planning information by knowledgeable persons, encouragement of couple communication and decision making, training of male health workers to discuss family planning with male groups, and increasing access to and availability of reversible methods.
Adolescent pregnancy has often been linked to the early childbearing of adolescents' mothers and to the perpetuation of poverty across generations. Using data on more than 3,000 20–24-year-old women and men from a representative household study in three Brazilian cities, Maria da Conceição Chagas de Almeida and Estela M.L. Aquino looked at patterns of intergenerational adolescent pregnancy and the role of education in continuing or breaking those patterns [see article]. Overall, both women and men were more likely to have had or been involved in an early pregnancy if their mother had had an adolescent birth. After adjusting for education in the final model of a stepwise regression analysis, the association between the mother's early birth and her daughter's early pregnancy disappeared, but the association between the mother's experience and her son's remained.
Also in This Issue
Jacqueline Sherris and colleagues report on progress made in developing screening approaches for cervical cancer in low-resource settings [see article]. Many women in developing countries will be able to obtain screening only once in their lifetime; screening carried out in their 30s has the greatest chance of detecting abnormalities at a treatable stage. Because obtaining high-quality Pap smears is difficult in low-resource settings, the most efficient and effective approach is screening women using either visual inspection with acetic acid (VIA) or HPV DNA testing, followed by cryotherapy if treatment is needed; this combination of screening and treatment can be carried out by physicians and mid-level health personnel in a single visit.
–The Editors