In Mexico, abortion laws are determined by states and are highly restrictive except in the Federal District (Mexico City), resulting in a lack of data about the subgroups who have the greatest need for interventions to prevent unwanted pregnancy and provide postabortion care. Using government statistics on postabortion patients and information obtained from health professionals on abortion complications, Fatima Juarez and Susheela Singh estimated 2009 abortion rates by women’s age and state of residence [page 58]. The abortion rate—38 per 1,000 women aged 15–44 for the country as a whole—ranged from 17.3 per 1,000 in Nuevo León to 59 per 1,000 in Tabasco. When states were grouped by socioeconomic development, the rate rose with the level of development, from 26–27 per 1,000 in the least-developed regions to 35–41 in the moderately developed regions and 54 per 1,000 in the Federal District, the most-developed region. Age-specific rates peaked among women aged 20–24 and then steadily declined with age, a pattern that held true nationally, regionally and in most states.
The Indian family planning program has historically relied heavily on sterilization, but has lagged in promoting use of reversible methods. As a result, many couples have several closely spaced births and then one of the spouses—usually the wife—is sterilized. Mary Philip Sebastian and colleagues evaluated an intervention integrated into the existing government program to increase awareness of healthy timing and spacing of pregnancies and use of postpartum spacing methods (including the lactational amenorrhea method) among pregnant young women through counseling by community workers [page 68]. At four months postpartum, women who had received the intervention were more likely than those in the comparison group to know about healthy timing and spacing of pregnancies. At nine months postpartum, women in the intervention group, women with higher knowledge of healthy spacing and those with correct knowledge about use of two or more spacing methods were more likely than other women to be using a reversible method. Use of modern methods for spacing at nine months postpartum was 57% in the intervention group, compared with 30% in the comparison group.
Women’s empowerment is thought to be associated with their control over their sexual and reproductive behavior and well-being; however, empowerment is difficult to define and measure, especially in differing contexts and cultures. The Demographic and Health Surveys (DHS) now incorporate standardized empowerment measures, but these measures—which include participation in household decision making and rejection of gender inequity within relationships—were developed for the South Asian context. Ushma Upadhyay and Deborah Karasek used DHS data for Guinea, Mali, Namibia and Zambia to determine whether these measures are associated with a desire for smaller families and with the ability to limit families to the desired size in Sub-Saharan Africa [page 78]. The results were inconclusive. In Guinea and Zambia, women who rejected proposed justifications for wife beating were more likely than women who accepted them to want smaller families; in Guinea, greater participation in household decision making was also associated with a desire for fewer children. Malian women who rejected justifications for wife beating had lower odds of having more children than they desired; however, Namibian women who had greater household decision-making power and Zambian women who supported women’s right to refuse sex with their husband were more likely to have more children than they wanted.
Empowerment also played a role in a study of treatment-seeking among young Indian women with recent symptoms of RTIs. According to analyses by Shagun Sabarwal and K.G. Santhya, just two-fifths of married women and one-third of unmarried women had sought treatment from a formal medical provider [page 90]. Married women who had experienced intimate partner violence were less likely to have sought treatment from a formal provider, but those who felt they could approach a provider for contraceptives and those who were aware of STI symptoms were more likely to have sought such treatment. Overall, both married and unmarried women were more likely to seek treatment from private than public providers. Being able to make independent decisions on personal matters increased the odds that married and unmarried women would choose a private provider, while having and managing one’s own bank or post office account and feeling able to approach a provider for contraceptives increased those odds only among unmarried women.
Guatemala has some of the largest health disparities in Latin America between ladina and indigenous women. Kanako Ishida and colleagues used DHS data to examine whether differences in language, socioeconomic status and residence translate to lower use by indigenous women of institutional prenatal care, institutional delivery and met demand for modern contraceptives [page 99]. The ethnic difference in use of prenatal care was small; however, indigenous women were far less likely than ladinas to deliver in an institution (36% vs. 73%), and indigenous women who did not want a birth in the next year were far less likely than their ladina counterparts to use modern contraceptives (49% vs. 72%). The fact that most indigenous women did not speak Spanish accounted for the largest portion of the difference in use of these two services. Indigenous women’s poorer education and concentration in rural areas made up smaller shares of the ethnic difference than did their economic disadvantage. The authors suggest that adding persons who speak local Mayan languages to the staff of health facilities may help increase indigenous women’s use of institutional delivery and modern contraceptives.