Menstrual regulation (MR)—a process to regulate or reestablish the menstrual cycle when menstruation has been absent for a short time—has been part of the national family planning program in Bangladesh since 1979, and studies suggest that the MR program has contributed to the sharp decline in maternal mortality in the country over the past two decades. Despite the success of the MR program, clandestine abortion remains a serious health problem in Bangladesh, where abortion is illegal except to save a woman’s life: In 2010, an estimated 647,000 induced abortions were performed, and 231,000 women were treated at health facilities for complications of unsafe abortion. 

In the lead article of this issue of International Perspectives on Sexual and Reproductive Health, Susheela Singh and colleagues use data from health facilities that provide MR or postabortion care services and from knowledgeable professionals to calculate the incidence of MR and induced abortion. In 2014, an estimated 430,000 MR procedures (using manual vacuum aspiration or medication) were performed in health facilities in Bangladesh, a decline of 34% since 2010. An estimated 1.2 million induced abortions were also performed, many of them likely by untrained providers or under unsafe conditions; 257,000 women were treated for abortion complications. Among women with complications, the proportion with hemorrhage was higher than it had been in 2010 (48% vs. 27%), which the authors suggest may reflect an increase in clandestine use of misoprostol to induce abortion. According to the authors, more attention needs to be paid to hiring and training new MR providers, and to instituting harm-reduction approaches to increase the safety of clandestine misoprostol use.

Pregnancy ambivalence and indifference are thought to be associated with nonuse of contraceptives, but their conceptualization and measurement vary across studies, and their relationship to contraceptive use in developing countries is poorly understood. Using data from 592 women in rural Lilongwe, Malawi, on their desire to conceive and their desire to avoid pregnancy, Sarah Huber and colleagues classified 12% as ambivalent, 32% as indifferent, 44% as antinatal and 12% as pronatal. The odds of contraceptive use among women with indifferent pregnancy desires (having both a desire not to avoid pregnancy and a desire not to conceive) were twice those among women with pronatal desires and similar to those among women with antinatal desires. In contrast, the odds of contraceptive use among women with ambivalent pregnancy desires (having both a desire to avoid pregnancy and a desire to conceive) did not differ from the odds among women who had pronatal desires. The authors suggest that family planning policies and programs may be more effective if they offer messages and interventions that address the mixed nature of pregnancy desires.

Levels of nonmarital childbearing, cohabitation and union dissolution have increased over the last several decades, leading to rising rates of multipartner fertility. Although multipartner fertility is increasing worldwide, little research on it has been conducted in lowand middle-income countries. Using data from the 2011–2012 Encuesta Nicaragüense de Demografía y Salud, Kammi Schmeer and Jake Hays found that 33% of mothers and 41% of fathers with two or more children had had children with more than one partner. Multipartner fertility was associated with lower current household wealth among mothers, and with increased risks of single parenthood and higher fertility among both mothers and fathers. Fathers with multiple fertility partners were more likely than those with one to report not providing financial support to, or sharing their surname with, one or more of their biological children. According to the authors, mothers with multiple fertility partners may be at elevated risk of raising children without the children’s fathers and with low economic support. In addition, they say, multipartner fertility may contribute to the problem of adolescent pregnancy in Nicaragua, given evidence that young women who do not live with their biological father during childhood and adolescence have earlier ages at first sex and first pregnancy. 

In Iran, rates of STIs are high and levels of STI knowledge in the general population are low. A few studies have suggested greater knowledge of STIs among college students, but were conducted only among those attending medical schools. In a survey of graduate and undergraduate students at five nonmedical public and private universities in the country, Mohammad Karamouzian and colleagues found that only about half of the respondents had ever heard of STIs, and the proportion who could correctly identify any given STI from a list of diseases and medical conditions exceeded 50% for only one item (hepatitis B–53%). Slightly smaller proportions identified genital herpes (49%), genital warts (46%) and gonorrhea (45%) as STIs. No more than half of respondents could correctly identify specific STI symptoms, and only about a third knew that STIs could be asymptomatic. Since students reported the Internet as their main source of STI information, the authors recommend increasing the accessibility and visibility of credible Internet sites on sexual health.
The Editors