According to United Nations projections, the total fertility rate (TFR) in Asia as a whole is expected to decline from 2.7 births per woman to an estimated 2.1 births per woman between 2000 and 2050, with replacement level fertility achieved in 2025. Nevertheless, the region's population is projected to grow by 44% during that period, from 3.5 billion to 5.0 billion. In Central, South and Southeast Asia, the fertility transition began later and is less advanced than in East Asia, where fertility has already dropped below replacement level.
Against this background, it is clear that in countries where fertility is still relatively high, the family planning service environment and the contraceptive and fertility behavior of today's adolescents and young adults are of critical importance. Three of the articles in this issue touch on one or both of these issues.
• In the lead article, Saroj Pachauri and K.G. Santhya examine data on adolescent women from nine countries in South and Southeast Asia to determine levels of knowledge about and use of contraceptive methods, as well as other fertility-related behaviors [see article]. They find that although awareness of contraception is almost universal, knowledge about specific methods and where to obtain them is limited. The percentage of married adolescent women using a modern method ranges from 2% in Pakistan to 44% in Indonesia, with prevalence generally higher in Southeast Asia than in South Asia. Despite a recent increase in contraceptive use in both regions, the level of unmet need exceeds 20% in four of the seven countries for which data are available. Given that adolescent marriage is commonplace in South Asia and that young women in both regions are often pressured to begin childbearing soon after marriage, the authors urge that reproductive health programs provide counseling to dispel misconceptions about contraceptive side effects and health concerns and to enhance negotiating skills.
• In Bangladesh, nongovernmental organizations (NGOs) have moved away from doorstep delivery of contraceptives and have begun offering services through clinics and satellite clinics that provide a broader range of reproductive health services, with contraceptive resupplies distributed through village depots. Sidney Schuler, Lisa Bates and Md. Khairul Islam assess the effects of the change on providers and clients [see article]. Although providers have been told that no client should be denied services for lack of money, the new service strategy also emphasizes cost recovery, and no formal system of determining eligibility for discounted or waived fees has been established. In an environment where most people are poor, this situation creates conflicts for providers and confusion and resentment among clients.
• Continuing the focus on services, Nguyen Minh Thang and Dang Nguyen Anh use Demographic and Health Survey data to examine the effect of accessibility on use of contraceptives in Vietnam [see article]. They find that 84% of Vietnamese women live within one kilometer of at least one source of family planning services, with access considerably higher in urban areas than in rural areas. After the effects of social and demographic characteristics are accounted for, both access to any source of family planning and access to more types of sources increase modern contraceptive use among women aged 25-34, those with at least a primary education and those with three or more children; greater access also decreases nonuse of modern methods and current use of traditional methods in the overall sample.
Also in This Issue
• In Mexico, abortion is legal under limited circumstances in all states, but the high rate of hospitalization for abortion complications suggests that some women who would qualify for legal services resort instead to illegal procedures, which are an important cause of maternal morbidity and mortality. One reason, according to an article by Davida Becker, Sandra G. Garcia and Ulla Larsen, may be lack of accurate information about the legal status of abortion. Using data from a nationally representative sample of young men and women, the authors determine that fewer than half of survey respondents knew that abortion was legal under some circumstances in their state; of the 54% who did not know, 82% believed that abortion was never legal and 18% that it was always legal [see article].
• Donor funding has considerable power to shape the delivery of the services it underwrites. Susannah H. Mayhew argues that political factors, donor "ownership" issues and failure to adapt international guidelines to local conditions have impeded the implementation of the integrated reproductive health agenda agreed on at the International Conference on Population and Health in Cairo.
• According to the lactational amenorrhea method, new mothers who are fully breastfeeding and amenorrheic are protected against pregnancy for six months after giving birth. Unfortunately, many providers in areas where pregnancy tests are not available are reluctant to provide such women with a hormonal method or an IUD until the return of menses. John Stanback and Heidi W. Reynolds urge providers to trust the three criteria for lactational amenorrhea to rule out pregnancy so that women who wish to continue practicing contraception can make a seamless transition to another method.