Little is known about the role that relationship types and processes play in adolescent pregnancy and childbearing in Sub-Saharan Africa. Using data on 365 romantic and sexual relationships from 298 female adolescents in southeastern Ghana, Jeffrey Bingenheimer and Kirsten Stoebenau found that pregnancy and childbearing occurred in 17% of relationships [see article]. The strongest predictors of adolescent fertility were marriage or cohabitation and the partner’s provision of basic financial support. The partner’s provision of gifts or money for things beyond basic needs was not associated with fertility, nor was financial motivation for starting the relationship. These findings suggest that adolescent fertility is occurring in more committed relationships, and that it may be best understood as a step in the process of family formation along a gendered pathway to adulthood. In this setting, only a small proportion of adolescent women complete secondary school, and many end up struggling to earn a living. The authors conclude that interventions that fail to address the paucity of educational and employment opportunities for young women may do little to reduce adolescent fertility in Ghana.

The female condom offers protection against HIV and other STIs as well as pregnancy, but its availability and uptake have remained low. According to in-depth interviews conducted by Julia Martin and colleagues with 14 women and 13 men in Cape Town, South Africa, the most important barrier to use was lack of familiarity with the method [see article]. Strong negative reactions from male partners were not a major problem, and participants reported that personal comfort and any tensions that arose with partners improved after the first use of the condom. Some male participants preferred the method because it shifts responsibility for condom use from men to women. According to the authors, their findings indicate that the female condom empowers women to initiate barrier method use, and that interventions designed to educate potential users about the method and familiarize them with it may be useful. They also suggest that counseling efforts should be directed toward men as well as women, and should emphasize that use of the female condom is a choice that couples should make together.

A substantial minority of births in rural southern Mozambique still occur at home, despite increases in facility births in the area overall. Some women may choose to deliver at home, but others face barriers related to distance or the cost or lack of transportation to a facility. For still others, roads to a facility may become impassable during the rainy season. Using a variety of data, Victor Agadjanian and colleagues found that women who had a higher number of clinics within 10 kilometers of their home were less likely than those with fewer nearby clinics to give birth at home; however, the closer women lived to an urban area, the more likely they were to do so [see article]. Women were more likely to have a home delivery during the rainy, high agricultural season, but wealth was negatively associated with home delivery. The authors conclude that efforts to increase physical access to health facilities in remote, hard-to-reach areas must continue. They note, however, that if the demands on women’s time, along with economic insecurity, represent major barriers to institutional delivery, more holistic interventions to improve women’s livelihoods are needed as well.

The Family Planning Program Effort Index has measured program activities in developing countries since 1972, focusing on policies, services, monitoring and evaluation mechanisms and access to methods. Results from the 2014 round, analyzed by Bernice Kuang and Isabel Brodsky [see article], show that overall program effort has progressed in all four component areas since 1999. Services improved by 7.6 percentage points, but remained the component with the weakest score (47% of maximum effort). Policies, with a 6.7 percentage-point increase, continued to be the strongest component (55% of maximum). Monitoring and evaluation improved the most, by 7.8 percentage points (to 53% of maximum), while the score for access rose by only 2.7 percentage points (to 52% of maximum). Family planning effort scores were generally strongest in Asia and Oceania and weakest in Central Asia and Eastern Europe. According to the researchers, these new data will help governments, nongovernmental organizations and international agencies more effectively allocate resources, identify shortfalls and devise country-customized approaches to improving family planning programs.

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The social and economic breakdown precipitated by armed conflict exposes young women to threats to their survival and their sexual and reproductive health. In such situations, Aisha Hutchinson and colleagues assert, notions of risk and protection may become context specific [see article]. Although early marriage may be seen as a risk to sexual and reproductive health in a stable environment, it may serve in conflict situations as protection from abduction by rebel militias, whose members may perpetrate severe and prolonged sexual violence on the young women they kidnap. Likewise, transactional sex may become a survival strategy or the only option through which young women can avoid starvation, even in refugee camps. The authors note that while such strategies may ensure survival in the short term, they can have many consequences for young women’s future sexual and reproductive health. Without wide-ranging and intensive support after conflict ends, they say, it may not be possible to reduce the long-term negative outcomes associated with early marriage and transactional sex.

The Editors