Over the last decade, as studies showed that individual, couple and household characteristics did not completely explain variations in contraceptive use, researchers began to look at community influences, including the physical, economic and social environment, cultural factors, and health care infrastructure, access and quality. In this issue of International Family Planning Perspectives, the influence of such factors is the focus of two articles, one in South Africa’s Eastern Cape province, where contraceptive prevalence is relatively high, and the other in Mali, where very few couples practice contraception.
Rob Stephenson and colleagues used multilevel multinomial analyses to examine the role of community and health facility influences on whether women used the pill or a more permanent method (the IUD, tubal ligation or vasectomy) instead of the injection, which accounts for 69% of use in Eastern Cape [see article]. The likelihood of using the pill rather than the injection was negatively associated with the number of community health workers in the area and the number of nurses at health facilities who had been trained on HIV/AIDS in the last year. Women in communities with higher numbers of expired contraceptives in stock weremore likely to reject the injection in favor of the IUD or sterilization. The likelihood of using either the pill or a more permanent method rather than the injection was positively associated with the proportion of women in the community who controlled their earnings and the number of doctors on staff at health facilities, and was negatively associated with the proportion of women who had only a primary education. The authors note, however, that even though the analyses controlled for individual and household variables, a substantial amount of variation in method choice across communities remained unaccounted for.
In Mali, fertility remains close to seven births per woman and only about 5% of married women practice contraception. Using data from the 2001 Demographic and Health Survey, Esther Kaggwa and colleagues examined the relative role that individual characteristics and community norms play in contraceptive use [see article]. The women most likely to use modern methods were those in the highest wealth quintile, those who approved of contraception and those whose partner approved, those who had had recent discussions on family planning with their partner or others, and those who had been exposed to family planning messages in the media. At the community level, the odds of modern method use rose with the proportion of women who had been exposed to family planning messages and declined as the mean number of births per woman rose. In the final model, which included both individual and community factors, the community variables were no longer significant. In settings where contraceptive use is very low, the authors suggest, programs should seek to increase individual approval and to encourage communication between partners.
Also in This Issue
•About one in 10 ever-pregnant Bangladeshi women have been physically abused by their spouse during pregnancy; of these, about onethird were punched or kicked in the abdomen, according to data from a World Health Organization multicountry study [see article]. Abuse generally began before conception, and was more likely to decrease or remain the same than to increase once the woman became pregnant. Overall, according to authors Ruchira Tabassum Naved and Lars Åke Persson, women whose mother or mother-in-law had experienced spousal violenceweremore likely than otherwomen to be abused during pregnancy, whereas increased spousal communication was associated with a lower risk of abuse. In urban areas, women who were older than 19 orwhose husband had 11 ormore years of education were less likely to be abused when they were pregnant than were younger women or those whose husband had less schooling, while community concern about crime was positively associated with spousal violence. In rural areas, women who could depend on their natal family for support during a crisis were less likely than those who could not to be abused during pregnancy; in contrast, women whose marriage had involved dowry demands and those who were Muslim were more likely than other women to experience spousal violence during pregnancy.
•Peer-led sexual health education interventions have been widely implemented, but a literature review by Caron Kim and Caroline Free finds little evidence that this approach is effective [see article].Of 13 studies that met the basic inclusion criteria—an appropriate comparison group, both baseline and postintervention data, and reporting of all outcomes—only threemet an additional 10 quality criteria and twomet nine criteria. Most interventions produced improvements in knowledge, attitudes and intentions, but few documented changes in behavior. One study reported a reduced risk of chlamydial infection, but another found no effect on STI incidence.One study found that young women (but not young men) who received peer-led education were less likely than nonrecipients to have ever had sex. No effects on condom use at last sex or consistent condom use were reported.
—The Editors