Social changes are reshaping sexual decision-making and behavior among urban adolescents in Mali," say Mouhamadou Gueye and colleagues (go to article). In this issue of International Family Planning Perspectives, they report on a research effort that combined quantitative and qualitative approaches to understand the timing and context of first intercourse among young people in Mali. Almost half of sexually experienced urban males said that their first intercourse was earlier than they would have preferred, compared with only about one-fifth of females. The young men often attributed their decision to have sex to peer pressure (including pressure from their girlfriends). And while young urban women who were surveyed usually said that their first sex was because of love, members of focus groups suggested that young urban women often had sex to obtain cash to meet their material needs. The authors observe that "increasing modernization and media exposure, along with a decline in the authority of parents and elders, have undermined the societal and cultural rules that formerly controlled and informed adolescent sexuality [in Mali]."
Two articles study issues concerning the delivery of reproductive health services. Quality of care and how it can be assessed is examined with great care by Ruth Bessinger and Jane Bertrand (go to article). The Quick Investigation of Quality was field-tested in 1998-1999 in Ecuador, Uganda and Zimbabwe, with information collected both from expert observations and from exit interviews with clients. Within each country, the two approaches to evaluation were rather consistent, and across all three countries agreement on individual measures was generally good or excellent. The authors conclude that while resource constraints might lead some programs to choose one approach over the other, taking a combined approach leads to a fuller assessment of quality of care.
In addition, Subrata Routh and colleagues assess the impact on contraceptive prevalence of basic changes made in service delivery in Bangladesh (go to article). During the 1990s, the Bangladesh family planning program began to shift from door-to-door distribution of contraceptives to a site-based service delivery. A before-and-after analysis suggests that this shift had no negative impact on women's contraceptive use, and may have increased it in some rural areas--especially reliance on injectable contraceptives.
M. Mazharul Islam and M. Mosleh Uddin report in this issue (go to article) on patterns in the prevalence of female genital mutilation in Sudan. Interviews with about 1,000 ever-married women in each of three areas of Sudan confirmed that while female circumcision is widely practiced in the north, it is relatively rare in the south. Half to two-third of women in the northern areas supported continuation of the practice, compared with almost none in the south. In high-prevalence areas, more highly educated and economically better off women were less likely to support female genital mutilation. The authors believe that female circumcision may be declining slightly in some areas of Sudan, and that education and economic empowerment of women would help reduce support for the practice.
Three studies in this issue address the complex issues affecting women's reliance on induced abortion. Valentine O. Otoide and colleagues conducted focus groups among Nigerian adolescents to identify reasons for their high reliance on unsafe abortion and low use of contraceptives (go to article). Many focus-group participants perceived that modern contraceptives have continuous and prolonged adverse effects on fertility. In contrast, they saw abortion as an immediate and simple solution to an unplanned pregnancy, and one that would have a limited negative impact on their future fertility. This finding emphasizes the need to educate adolescents about how contraceptives work and what their side effects are compared with those of unsafe abortion.
In addition, Pinar Senlet and colleagues detail the history of a carefully thought out effort to reduce high levels of abortion use in Turkey (go to article). A pilot program to encourage postabortion family planning use was launched in the early 1990s at a hospital in Ankara. In one year, the percentage of abortion clients leaving the facility with a modern contraceptive increased dramatically, and in subsequent years the annual number of abortions provided there dropped. The program was replicated at 10 more large public hospitals, and then in Istanbul and elsewhere, also with great success. The authors believe that the postabortion family planning program contributed to a decline in abortion in Turkey, both by increasing contraceptive use overall and by shifting the method mix toward more effective methods.
Finally, Clement Ahiadeke (go to article) takes a unique approach to examining the incidence of induced abortion in Ghana. Nearly 1,700 pregnant women were identified and the outcomes of their pregnancies monitored prospectively; more than 300 terminated their pregnancies, for an abortion rate in the study areas of 17 induced abortions per 1,000 women of childbearing age. Three women in five who had an abortion were younger than 30, nearly half obtained an abortion before the seventh week of gestation and only one in eight obtained their abortion from a physician. The author comments that just 11 women in the study had used contraceptives prior to becoming pregnant, but that all of the women who obtained an abortion had already had a previous abortion, and observes that they send "a serious message about the underutilization of family planning services in Ghana."