Family planning methods are almost universally known in Cambodia, and most women regard them as affordable and available. Nevertheless, only one in four married women were using a method in 2005, and a comparable proportion said they wanted to delay or stop childbearing but were not using a method. With a representative sample of more than 700 married rural women who wanted to delay or prevent future pregnancies, Ghazaleh Samandari and colleagues explored the possibility that social factors play a role in keeping contraceptive use low [see article]. Overall, 43% of the women were using a modern method. In multivariate analyses of the total sample, women were more likely to use a modern method if they believed their husband thought it was a good idea, and less likely to do so if they were nervous about discussing it with him. In general, these findings held for both women who had 0–2 children (low-parity) and those who had three or more (high parity). The odds of contraceptive use were decreased for all women and high-parity women whose husband made the final decision about use, and elevated among low-parity women who thought that most of their peers practiced contraception. In all three groups, use was lower among women who believed they should follow the dictates of village elders who said they should not practice contraception. The authors recommend that family programs focus on increasing men's approval of contraception, improving partner communication on family planning and bolstering women's confidence in their reproductive decision making.
Despite efforts to curtail the early marriage of girls and young women in India, nearly half of women in their early 20s still report having married before they were 18, and little is known about how their marital and reproductive health outcomes differ from those who married later. K.G. Santhya and colleagues use data on women aged 20–24 from a large-scale survey conducted in urban and rural areas of five states where early marriage is widespread to shed light on this question [see article]. Young women who had married at age 18 or older were more likely than those who had married earlier to have been involved in planning their marriage, to reject wife beating, to have used contraceptives to delay their first pregnancy and to have had their first birth in a health facility. Compared with women who had married early, they were less likely to have experienced physical or sexual violence in their marriage or to have had a miscarriage or a stillbirth. According to the authors, their findings underscore the need to build support within families for delaying marriage, to enforce existing laws barring early marriage and to build support for young women who wish to delay marriage.
In settings where recourse to unsafe abortion is widespread, the physical, social and economic burden of abortion morbidity to women is largely unmeasured. Laura Nyblade and colleagues conducted a population-based study in Madhya Pradesh, one of India's poorest states, to capture the level of morbidity through two measures—one based on women's reports of severity of complications and the other based on self-reported days of bed rest, a proxy for the degree of disruption of everyday life [see article]. The symptoms measure recorded morbidity in 58% of abortion attempts in rural areas and 46% in urban areas; the comparable proportions for the bed-rest measure were 38% and 29%, respectively. According to both measures, the proportion of attempts resulting in severe morbidity were higher in rural than in urban areas. The authors note that their findings demonstrate not only the high level of abortion-related morbidity in Madhya Pradesh, but the value of measuring morbidity in ways that capture both clinically observable symptoms and the effects of morbidity on women's lives.
The female condom is underused among female sex workers in Central America as a means of protection against HIV infection. To help program managers develop strategies for promoting the device, Natasha Mack and colleagues conducted structured interviews and two rounds of focus groups among sex workers in El Salvador and Nicaragua, as well as direct observations of health educators who worked with the women [see article]. Many of the sex workers initially found the device difficult to use, and needed to practice insertion and removal up to 10 times by themselves before feeling comfortable enough to use it with a partner. They preferred that the condoms be made available in places where obtaining them would not carry stigma, such as pharmacies, clinics and places of employment (bars or hotels, for example), and that program staff educate providers in these venues and other distribution points about the condoms. The authors note that programs also need to engage in long-range planning to address the inconsistent availability of female condoms for distribution.
Also in This Issue
In a Viewpoint, James Shelton challenges public health programs and nongovernmental organizations to acknowledge the potential of masturbation to help reduce the spread of AIDS around the world [see article]. By talking openly with clients about achieving sexual satisfaction through masturbation, he argues, reproductive health care providers can give them another means of avoiding risky sexual situations in which they might transmit or be infected by HIV.