Reproductive health programs using multiple approaches have been associated with increased contraceptive knowledge and use in the short term. However, little is known about whether these changes persist over time and whether they lead to new community norms. In this issue of International Perspectives on Sexual and Reproductive Health, Shireen Jejeebhoy and colleagues report on an evaluation study showing that positive outcomes linked to the Promoting Change in Reproductive Behavior project were sustained for up to eight years after the end of the program [page 115]. Compared with young women living in areas not included in the project, those in the intervention areas were more likely to have knowledge about specific methods of contraception, to have ever used contraceptives or modern methods, and to have initiated contraceptive use within three months of their first birth. These positive differences were found not only among women directly exposed to intervention messages and activities, but for some measures among indirectly exposed women as well, suggesting that new norms concerning contraception may have spread throughout the community.

Despite decades of evidence-based advocacy for family planning in developing countries, research on how decision makers perceive and respond to such efforts is lacking. According to interviews conducted by Ellen Smith and colleagues with key informants in government and in nongovernmental organizations in Ethiopia, Kenya and Malawi, decision makers confirmed that advocacy had helped to spur favorable shifts in government support of family planning [page 136]. They noted, however, that advocacy messages must consider barriers to decision makers’ support for family planning—constituents’ negative attitudes; fear that increased contraceptive use could shrink the size and influence of specific voting blocs and ethnic groups; and competing economic, social, cultural, religious and political priorities. Although decision makers reported valuing the involvement of international family planning organizations and donors, they were more comfortable receiving advocacy messages from local sources who understand the issues and the context.

Family planning programs in Sub-Saharan Africa have generally marketed the female condom as a means of increasing women’s control of contraception and protection against infection. However, rates of use of the device remain low in the region. According to a qualitative study by Winny Koster and colleagues among men in Cameroon, Nigeria and Zimbabwe, men in all three countries favored the method over other means of protection for its enhancement of sexual pleasure, as well as its effectiveness and lack of side effects [page 126]. Generally, men preferred using the female condom with stable rather than casual partners, and for contraception rather than HIV protection. However, in all three countries, men considered it unacceptable for a woman to initiate female condom use, suggesting that marketing the device as a means of female empowerment may not be productive. The authors suggest that in Sub-Saharan Africa, where decisions about sex and contraception are considered men’s prerogative, marketing strategies aimed at both men and women may be the best way to increase use.

Increases in use of modern contraceptives in Malawi over the last two decades have not translated into a commensurate reduction in fertility. Using contraceptive service data from a one-year prospective study in Karonga, a demographic surveillance site, Aisha Dasgupta and colleagues examined whether inconsistent long-term use of short-term methods such as the injectable—currently the predominant method in Malawi—could contribute to this disparity [page 145]. According to the contraceptive service data, only 51% of injectable users received their first reinjection on time, and just 15% adhered to the method for 12 months. In addition, the proportion of women in Karonga using the injectable at seven months, as estimated from service data (14%), was considerably lower than the proportion estimated from cross-sectional data from the Malawi Demographic and Health Survey (20%), suggesting that the former estimate picked up discontinuation and gaps in use not captured by the period prevalence measure from the survey.

Decisions on programmatic guidelines about the optimal time for women to initiate method use after a birth are complicated by abstinence and breast-feeding–induced amenorrhea, according to a Comment by John Cleland and colleagues [page 155]. Using data from recent Demographic and Health Surveys, the authors find that the majority of women in low-income countries wait for their menses to return before starting contraception. In countries where the duration of amenorrhea is short, they say, the current consensus to recommend immediate or early postpartum initiation of use is valid; however, in countries where amenorrhea lasts for around 12 months, as in most of Sub-Saharan Africa, women who begin use early in the postpartum period may discontinue it at about the time their fertility returns. The authors argue that in such countries, women should be given the choice of postponing use of contraceptives until menses return and accurate information on the associated risk of pregnancy.

The Editors