Not all of the many choices people make regarding their reproductive health are in their own best interests. For this reason, providers are constantly seeking means of helping their clients make healthier choices or of intervening before unhealthy choices lead to untreatable problems. The articles in this issue of International Family Planning Perspectives focus on research designed to identify such interventions.
Contraceptive users tend to continue use longer if they obtain the method they want and are well-informed about the benefits and potential side effects associated with it. In the lead article, Young Mi Kim and colleagues evaluate a flipchart designed by the World Health Organization to improve the quality of family planning counseling so that clients receive the method that best suits their needs [see article]. The two-sided flipchart functions both as a job aid for providers and as a decision-making tool for clients. Videotapes of counseling sessions—made before and after a group of providers were trained to use the flipchart—showed that after being trained, the providers gave their clients more information and tailored that information more closely to clients' individual needs and desires. Clients became more involved and active in the decision-making process, resulting in a shift from provider-dominated to shared decision making.
Kelly Blanchard and colleagues look at another intervention point—the period between unprotected intercourse and unplanned pregnancy [see article]. Emergency contraceptive pills reduce a woman's risk of pregnancy by at least 75% if taken within 72 hours after unprotected sex. Many women, however, have difficulty obtaining emergency contraception within this short period, either because of their own lack of knowledge or because of misinformation and negative attitudes among providers. Of pharmacists surveyed by the researchers in two areas of Johannesburg, South Africa, half believed repeat use of the pills posed health risks, a similar proportion did not think the pills should be available to women younger than 18 and one-quarter would not sell them to women with a late menstrual period.
Some couples are at risk of unintended pregnancy because the partners want different numbers of children or have not discussed how many children they will have. Using data on pregnancies ending in live births from a nationally representative survey of Salvadoran men, Marion Carter and Ilene Speizer found that one-quarter of such pregnancies in the last five years had been unintended from the men's perspective. Of these unintended pregnancies, slightly more than half had occurred when the man was not doing anything to avoid conception, and 20% had occurred to a man and woman with discordant pregnancy intentions. The authors recommend that programs involve both partners in family planning counseling to help them clarify their ideal family size and choose an appropriate method.
As a last resort, a woman with an unintended pregnancy may seek an abortion, even when the procedure is prohibited. In Uganda, where abortion is illegal except to save a woman's life, Susheela Singh and colleagues estimate that nearly 300,000 pregnancies (one of every five) each year end in induced abortion [see article]. As a result of the circumstances in which these procedures are performed, 85,000 women a year are treated for abortion complications. According to the authors, these figures reflect the high proportion of pregnancies that are unintended (50%) and the high level of unmet need for effective contraception among married women (51%). Programs, they say, need to focus on improving the mechanisms of contraceptive supply and ensuring continuous availability of supplies. —The Editors
For young people, promotion of condom use to prevent infection with sexually transmitted infections (particularly HIV) is critical. Using data from nearly 2,000 adolescents and young adults in Luanda, Angola, Ndola Prata and colleagues examine how gender and type of relationship affect predictors of two measures of condom use. Regardless of gender, respondents who had higher levels of education and did not believe that condoms diminish sexual pleasure were more likely to use condoms consistently with all their partners. Females were less likely to use condoms consistently if they equated their use with lack of trust; males were more likely to do so if they had multiple partners or believed condoms are safe. Living in a urban area, having a higher level of education, being in school and not equating condom use with lack of trust were important predictors of use at last intercourse in regular and casual relationships, whereas access to condoms was the most important factor in spousal relationships. The authors recommend that programs address negative attitudes and misperceptions about condoms among youth.