Women's Empowerment and Contraceptive Use: The Role of Independent versus Couples' Decision-Making,from a Lower Middle Income Country Perspective

Introduction

There is little available evidence of associations between the various dimensions of women''s empowerment and contraceptive use having been examined - and of how these associations are mediated by women''s socio-economic and demographic statuses. We assessed these phenomena in Pakistan using a structured-framework approach.

Methods

We analyzed data on 2,133 women who were either using any form of contraceptive or living with unmet need for contraception. The survey was conducted during May - June 2012, with married women of reproductive age (15–49 years) in three districts of Punjab. The dimensions of empowerment were categorized broadly into: economic decision-making, household decision-making, and women''s mobility. Two measures were created for each dimension, and for the overall empowerment: women''s independent decisions, and those taken jointly by couples. Contraceptive use was categorized as either female-only or couple methods on the basis of whether a method requires the awareness of, or some support and cooperation from, the husband. Multinomial regression was used, by means of Odds Ratios (OR), to assess associations between empowerment dimensions and female-only and couple contraceptive methods.

Results

Overall, women tend to get higher decision-making power with increased age, higher literacy, a greater number of children, or being in a household that has superior socio-economic status. The measures for couples'' decision-making for overall empowerment and for each dimension of it showed positive associations with couple methods as well as with female-only methods. The only exception was the measure of economic empowerment, which was associated only with the couple method.

Conclusion

Couples'' joint decision-making is a stronger determinant of the use of contraceptive methods than women-only decision-making. This is the case over and above the contribution of women''s socio-demographic and economic statuses. Effort needs to be made to educate women and their husbands equally, with particular focus on highly effective contraceptive methods.     

Fathers' decline in testosterone and synchrony with partner testosterone during pregnancy predicts greater postpartum relationship investment

The transition to parenthood has been associated with declines in testosterone among partnered fathers, which may reflect males' motivation to invest in the family. Moreover, preliminary evidence has found that couples show correlations in hormone levels across pregnancy that may also be linked to fathers' preparation for parenthood. The current study used repeated-measures sampling of testosterone across pregnancy to explore whether fathers' change in T, and correlations with mothers' T, were associated with fathers' and mothers' postpartum investment.In a sample of 27 couples (54 individuals) expecting their first child, both parents' salivary testosterone was measured multiple times across pregnancy. At approximately 3.5 months postpartum, participants rated their investment, commitment, and satisfaction with their partner. A multilevel model was used to measure change in testosterone over time and associations between mother and father testosterone. Fathers who showed stronger declines in T across pregnancy, and stronger correlations with mothers' testosterone, reported higher postpartum investment, commitment, and satisfaction. Mothers reported more postpartum investment and satisfaction if fathers showed greater prenatal declines in T. These results held even after controlling for paternal investment, commitment, and satisfaction measured prenatally at study entry.Our results suggest that changes in paternal testosterone across pregnancy, and hormonal linkage with the pregnant partner, may underlie fathers' dedication to the partner relationship across the transition to parenthood.     

Determinants of spacing contraceptive use among couples in Mumbai: a male perspective

This study aimed to determine the factors influencing the use of spacing contraceptive methods in India, particularly from men's perspective. Data were obtained through a semi-structured interview schedule from 2,687 married men aged between 18 and 40 years from central Mumbai City, India, during 1999. Chi-squared tests and binary logistic regression analysis was carried out to determine the relationship between various variables and the likelihood of a couple using spacing contraceptive methods. Of the 2,687 couples, 1,395 (51.9%) were using one or other method of spacing contraceptives and 1,292 (48.1%) were not using any method at the time of survey. Male participation in contraceptive use was 23% (condom and withdrawal). The results indicate that the use of spacing contraceptive methods was significantly higher among those couples where the men desired one or two children (OR=4.3), had knowledge of five or more contraceptive methods (OR=1.9) and discussed with their wives obtaining family planning information (OR=3.2), spacing (OR=2.7) and permanent (OR=2) contraceptive methods. Age, income, desired number of children, knowledge of a greater number of contraceptive methods, inter-spouse communication regarding obtaining family planning information, spacing and permanent methods were found to be strong predictors of the use of spacing contraceptive methods. The study underlines the importance of intervention programmes aimed at promoting a small family norm, increasing the number of contraceptive choices available and encouraging inter-spouse communication. Hence, policymakers and programme managers should encourage interventions in this direction, targeting couples to enhance the use of spacing contraceptive methods.     

Pregnancy Incidence and Correlates in a Clinical Trial Preparedness Study,North West Province South Africa

Introduction

Women in HIV prevention trials often must typically agree to avoid pregnancy. Regardless, some become pregnant. Screening tools predicting pregnancy risk could maximize trial safety and efficiency.

Objectives

We assessed incidence and correlates of pregnancy among women at high HIV risk.

Methods

We enrolled sexually-active, HIV-negative women into an observational cohort (2008–2011). At enrolment demographic, contraceptive, reproductive, pregnancy intention and behavioural data were collected. Women reported if one or both partners wanted or intended for the couple to become pregnant. We measured gender role beliefs using a locally validated eight-point index. We tested HIV and pregnancy, and inquired about sexually transmitted infection symptoms (STIs) at enrollment and monthly. HIV testing included behavioural counselling and condom provision, but did not specifically counsel women to avoid pregnancy. Cox proportional hazard modelling evaluated the associations with pregnancy. The multivariate model included the following variables “Recent pregnancy attempts”, “Gender Roles Beliefs”, ”Self-reported STIs” and “Age”.

Results

We screened 1068 women and excluded (24.6%, 263/1068) who did not report risk behaviour. Non-pregnant, non-sterilized women aged 18–35 (median = 21 years) enrolled (n = 438). Most women reported one partner (74.7%) and a prior live birth (84.6%). Median follow-up time was 6 months (range 0.7–15.5). Pregnancy incidence was 25.1 per 100 women-years (n = 57 pregnancies). Conservative beliefs on gender roles (Adjusted Hazard Ratio (aHR) 1.8; 95% confidence interval [CI] 1.1–2.9), recent pregnancy attempts (aHR 1.9; 95% CI 1.1–3.4) and baseline self-reported STI (aHR 2.5; 95% CI 1.4–4.4) were associated with increased incident pregnancy. Report of no pregnancy intention was associated with lowered pregnancy risk (aHR 0.3; 95% CI 0.1–0.7).

Conclusions

We identified new and confirmed existing factors that can facilitate screening for pregnancy risk.     

Antenatal screening for carriers of cystic fibrosis: randomised trial of stepwise v couple screening.

OBJECTIVE--To perform a rigorous comparative evaluation of stepwise and couple approaches to antenatal carrier screening for cystic fibrosis. DESIGN--Pragmatic randomised trial. SETTING--Hospital antenatal clinic serving a regional population. SUBJECTS--2002 women (couples) attending for booking antenatal visit at less than 17 weeks'' gestation with no family history of cystic fibrosis. INTERVENTIONS--Offering counselling and carrier testing for cystic fibrosis, either to women in the first instance (stepwise) or to couples (couple screening). MAIN OUTCOME MEASURES--Uptake rates; anxiety; knowledge of cystic fibrosis and carrier status (both partners); attitudes to health, pregnancy, the baby, and screening (both partners); and uptake of carrier testing by relatives. RESULTS--Uptake of screening was the same for both approaches (90%). After delivery most women remembered test results and their meaning, but 53/253 (21%) of those with negative results of couple testing had forgotten that repeat testing would be advisable if they had a pregnancy with a new partner. With stepwise screening women identified as carriers had high levels of anxiety when results were received (mean anxiety score 52.3). This dissipated with a reassuring partner''s result (carriers'' mean anxiety score 36.1) to levels similar to those receiving negative results from couple screening. Of those receiving negative results, women who had stepwise screening were significantly less anxious than those who had couple screening (mean score with result 32.1 v 35.4, 95% confidence interval for difference -4.7 to -2.1). CONCLUSIONS--Couple screening allows carriers to avoid transient high levels of anxiety, but is associated with more anxiety and false reassurance among most screenees who will test negative. Stepwise screening gives carriers and their relatives genetic information and is, in our opinion, the better method.     

Barriers to Sustained Use of Contraception in Nepal: Quality of Care,Socioeconomic Status,and Method-Related Factors

Owing to previously limited data availability, low contraceptive prevalence, and predominance of permanent method use in Nepal, there have been few studies of contraceptive-use dynamics. The aim of this article is to examine contraceptive use dynamics in Nepal in light of the country's ongoing fertility transition and change in contraceptive method-mix. Drawing on the 2003 Contraceptive Acceptance and Use Patterns Survey of Nepal and the quality-of-care framework, a proportional hazards model is used to explore contraceptive discontinuation of injections and pills. Results show that source of method from non-government services, high level of information given, one-to-one counseling, satisfaction with services, and shorter travel time to source are associated with lower odds of discontinuation. Despite the experience of side effects, women in Nepal are highly motivated to regulate their fertility. Results suggest detailed information given to users can have significant influence on continuation of methods rather than merely providing information on alternative methods and group counseling.     

Antenatal screening for cystic fibrosis: a trial of the couple model.

OBJECTIVE--To assess the delivery and acceptability of antenatal couple screening for cystic fibrosis. Carrier status was notified only when both members of a partnership had cystic fibrosis alleles and therefore a one in four risk of having an affected child. DESIGN--Mouthwash samples were tested when both partners participated. Results were returned only to positive couples. SETTING--Two large maternity hospitals in Edinburgh. SUBJECTS--Screening was offered to all couples who booked at one of the two hospitals. MAIN OUTCOME MEASURES--(a) The take up of screening, carriers and carrier couples identified, take up of prenatal diagnosis, and numbers of affected fetuses detected; (b) questionnaire measures of patient satisfaction and stress. RESULTS--Screening was offered to 8536 couples. 714 (8.4%) were regarded as ineligible, usually because of late booking or absence of a partner. 1900 (24.3%) of the remainder declined screening. Among the 5922 screened couples, four tested positive--that is, both partners were cystic fibrosis heterozygotes. All four elected to have prenatal diagnosis. There were three terminations of pregnancy because of an affected fetus, one couple having two successive pregnancies with affected fetuses. The participation rate was 76% for eligible couples (5922/7822) and 69% for all couples (5922/8536). Only 89 screened couples (1.5%) requested information on individual carrier status. No anxiety was detected among a cohort of the screened population, and 99% of questioned participants expressed satisfaction with the concept of couple screening. CONCLUSIONS--Antenatal couple screening is a satisfactory and acceptable way of screening for cystic fibrosis and has been adopted as routine in the two trial hospitals.     

Effects on pregnancy outcome of changing partner between first two births: prospective population study

Objective To compare the effects on pregnancy outcomes of changing partner between the first two births with having the same partner for both births.Design Prospective population study.Setting Norway.Participants 31 683 women who changed partner between their first two births and 456 458 women with the same partner for both births.Results After adjustment for maternal age and education, interval between births, and decade of birth, the risk of adverse pregnancy outcomes for the second birth was higher for women who changed partner between the first two births compared with those who had the same partner for both births: preterm birth (< 37 weeks; relative risk 2.0, 95% confidence interval 1.9 to 2.1), low birth weight (< 2500 g; 2.5, 2.3 to 2.6), and infant mortality (1.8, 1.6 to 2.1). For the first birth, the risk of these adverse pregnancy outcomes was only slightly higher for mothers who subsequently had a second birth with another partner.Conclusion Women who change partner between their first two births are at an increased risk of delivering a preterm, low birthweight baby with an increased risk of infant mortality compared with women who have the same partner for both births.     

Sequence of events following adoption of contraception: An exploratory analysis of 1973 fertility history data

Abstract

Fertility histories from the 1973 United States National Survey of Family Growth are analyzed in the context of a model of contraceptive use based on a Semi‐Markov processes. This model provides a means of constructing data‐based estimates of probabilities of pregnancy following initial acceptance of a contraceptive method. The algorithm used to construct these estimates recognizes multiple intervals of contraceptive used prior to the events: pregnancy, marital dissolution, or sterilization.

Estimated probabilities of the events marital dissolution and pregnancy for women seeking to delay pregnancy are presented, as are probabilities of contraceptive sterilization for women seeking to prevent subsequent pregnancy. These estimates are compared to one‐step transition probabilities and directly observed NSFG data on pregnancy, marital dissolution, or contraceptive sterilization in an attempt to judge the validity of the model and to assess biases which may result from its use.     

Guidelines to birth control counselling of the physically handicapped.

Birth control counselling of well motivated physically handicapped men and women is discussed in a series of suggested steps: (1) preappointment arrangements are made to ensure physical access to the office, and the partner or a helper may be invited to the visit; (2) the patient is encouraged to name the desired birth control method; (3) the patient''s fertility is established from the history and the results of physical examination and laboratory tests; (4) methods of birth control are matched to the patient''s physical and mental capabilities; (5) potential side effects of the proposed methods are considered in the light of the handicap; (6) a method is finally recommended that may be a trade-off, with ease of use balanced against efficacy, and living with side effects balanced against the risks of pregnancy; and (7) rechecks are necessary to ensure that the patient is using the method with skill and satisfaction.     

Men's involvement in family planning in rural Bangladesh

Contraceptive prevalence has risen markedly in rural Bangladesh due in part to a doorstep-delivery system initiated by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). This study investigates effects of residence in the Matlab MCH-FP treatment area on men's involvement in family planning. The analysis compares for treatment and comparison areas knowledge of and attitudes toward contraception, as well as levels of contraceptive use, among 413 married men interviewed at the baseline of an ICDDR,B men's involvement project. Although residence in the MCH-FP area is associated with a higher overall contraceptive prevalence, it also is associated with a lower adjusted ratio of male-to-female method use, and lower odds of other indicators of men's involvement in family planning. Historical decisions to exclude men from contraceptive decision-making may place the 'burden' of contraception on women and may preclude the productive involvement of men. These and other implications and strategies for increased men's involvement are discussed.     

Cystic fibrosis carrier testing in early pregnancy by general practitioners.

OBJECTIVE--To assess the feasibility of genetic counselling in general practice by using cystic fibrosis carrier screening at the booking appointment as an integral part of routine antenatal care and as a paradigm for the wider participation of general practitioners in medical genetics. DESIGN--Maternal testing (male partner tested only if woman screens positive) and couple testing for cystic fibrosis carrier status in the antenatal population attending one general practice and, later, in a further six (outreach) practices also. SETTING--Two partner urban training practice (pilot practice) in south Manchester, and six north west practices (two inner city, three urban, one rural dispensing). SUBJECTS--Total practice population of 50,000 (pilot practice plus six outreach practices) with an estimated 500-800 pregnancies per year. MAIN OUTCOME MEASURES--(a) Proportion of carriers of cystic fibrosis identified, counselled, and appropriately managed within the first trimester of pregnancy; (b) questionnaire and interview measures of patient satisfaction and stress. RESULTS--Eleven carriers of cystic fibrosis were detected including one carrier couple. This carrier couple, after extensive counselling, elected to have prenatal diagnosis by chorionic villus biopsy. The fetus was homozygous normal. CONCLUSIONS--General practitioners can successfully integrate genetic counselling and cystic fibrosis carrier screening into the first antenatal booking appointment. When a carrier couple is identified clinical geneticists can help with the discussion of reproductive options, and prenatal diagnosis by chorionic villus biopsy can be completed within the first trimester. The results suggest that general practitioners will have an increasingly important role in medical genetics, subject to continuing evaluation of patient acceptability and stress.     

Abortion as a backup method for contraceptive failure in China

Contraceptive failure rates for modern methods including sterilization are reported to be high in China, but little is known about the consequence of contraceptive failure and characteristics of women who decide to have an abortion if a contraceptive failure occurs. Using 6225 contraceptive failures from the 1988 Chinese Two-per-Thousand Fertility Survey, this study examines the resolution of contraceptive failure and assesses the impact of some women's sociodemographic characteristics on the decision to terminate contraceptive failure in abortion. This study has three important findings: (1) The abortion rate was 50.1%, 75.3% and 80.2% for IUD, condom and pill failures, respectively; (2) The abortion rates differed by contraceptive method and women's social and demographic characteristics. In particular, a woman with just one child was most likely to have the contraceptive failure aborted; (3) Some women experienced repeated abortions because of contraceptive failure. The results suggest that abortion was a backup method if contraception failed in China and the correlates of aborting an unwanted pregnancy reflect the strong impact of the Chinese family planning programme.     

A study of contraception as related to unwanted pregnancy

A study was made of 150 women requesting therapeutic abortion. Mechanical failure of the contraceptive method used accounted for unwanted pregnancy in 89 (59%) women. In the remainder no method of contraception was used by either partner. Among women requesting abortion, failure to use contraceptives was commoner in the younger and unmarried than in older and married women.The data obtained were analyzed in an attempt to explain the failure and avoidance of contraception. Suggestions are made as to how to discourage the use of abortion as a method of contraception.     

Psychological Antecedents to Conception Among Abortion Seekers

At a university hospital, 642 women seeking induced abortion for an unwanted pregnancy were surveyed before the procedure regarding their perception of what psychological and behavioral factors, if any, played a role in their becoming pregnant: 35 percent said they had had intercourse during what they believed was a “safe period”; 33 percent believed that they had experienced a contraceptive failure; 29 percent indicated fear of side effects influenced their use of a contraceptive method; 27 percent and 21 percent, respectively, indicated that they had thought pregnancy “couldn''t happen to me” or had “put the thought of pregnancy out of my mind.” The women''s responses indicated that a number of additional attitudes, beliefs, and behaviors were also important and that for any individual woman at least three or four factors had often combined in a dynamic sequence to greatly increase her risk of pregnancy. The implications of the findings for educational and counseling programs are discussed.     

Comparing the effectiveness of copper intrauterine devices available in Canada. Is FlexiT non-inferior to NovaT when inserted immediately after first-trimester abortion? Study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: We describe the rationale and protocol for a randomized noninferiority controlled trial (RCT) to determine if the Flexi-T380(+) copper intrauterine contraceptive device (IUD) is comparable in terms of effectiveness and expulsion rates to the most common Canadian IUD currently in use, NovaT-200, when placed immediately after a first-trimester abortion. METHODS: Consenting women choosing to use an IUD after an abortion for a pregnancy of less than 12 weeks of gestation will be randomized to device-type groups to receive immediate post-abortion placement of either a Flexi-T380(+) IUD, a device for which no current evidence on expulsion or effectiveness rates is available, or the Nova-T200 IUD, the only other brand of copper IUD available in Canada at the time of study initiation. The primary outcome measure is IUD expulsion rate at 1 year. Secondary outcomes include: pregnancy rate, method continuation rate, complication rates (infection, perforation), and satisfaction with contraceptive method. A non-intervention group of consenting women choosing a range of other post-abortion contraception methods, including no contraception, will be included for comparison of secondary outcomes. Web-based contraception satisfaction questionnaires, clinical records, and government-linked health administrative databases will be used to assess primary and secondary outcomes. DISCUSSION: The RCT design, combined with access to clinical records at all provincial abortion clinics, and to information in provincial single-payer linked administrative health databases, birth registry, and hospital records, offers a unique opportunity to determine if a novel IUD has a comparable expulsion rate to that of the current standard IUD in Canada, in addition to the first opportunity to determine pregnancy rate and method satisfaction at 1 year post-abortion for women choosing a range of post-abortion contraceptive options. We highlight considerations of design, implementation, and evaluation of the first trial to provide rigorous evidence for the effectiveness of current Canadian IUDs when inserted after first-trimester abortion.Trial registrationClinicalTrials.gov Identifier NCT01174225.     

Contraceptive practice of Irish married and single first-time mothers

This study surveys 100 married and 100 unmarried primiparous mothers, attending the National Maternity Hospital, Dublin, with regard to their contraceptive practice, their planning of their pregnancy and the timing of their first antenatal visit. Nineteen per cent of the married women, but 64% of the unmarried women, had never used any contraceptive method. The contraceptive pill was the most popular method for both groups, but while three in five of the married women had at some time used the pill, only a little more than one in five of the unmarried women had ever used it. One quarter of the women who had used contraception reported that their pregnancy was the result of a failure in their contraceptive method. Eighty-nine per cent of the single group and 20% of the married had not planned their pregnancy. None of the married women, but almost a quarter of the single, delayed their first antenatal visit until after they were 20 weeks pregnant.     

Sociodemographic attributes of Iranian wives who reported unwanted pregnancies

In a 1989 Family Planning Study in Iran, 40 percent of the married women of reproductive age reported that their last or current pregnancies were unwanted and unintended. This finding is consistent with the results obtained from a number of studies undertaken in the countries of North Africa and the Middle East. Although the phenomenon of unwanted pregnancy is a significant topic in the population studies, it has received very little attention. This paper shows the differences between two groups: group A, those married women who reported that their last or current pregnancies were wanted, and group B, those married women who reported that their last or current pregnancies were unwanted. The findings of this study clearly show significant differences between these two groups in regard to some key sociodemographic attributes: wife/husband's education, actual and desired fertility, wife's current age, past and present practice of contraceptive methods, and extent of satisfaction with family planning services are among the attributes differentiating these two groups. Our examination of these variables suggests that group B had higher parity, fertility, less desire for more children, less use of contraceptive techniques, and less satisfaction with the efficiency of the contraceptive techniques than group A. The relationship between education and wanted/unwanted pregnancies is mixed. The urban women who wanted pregnancies and were 25 years old or older were more educated than those who did not want pregnancies. On the contrary, the rural women whose pregnancies were not wanted were more educated than those who wanted pregnancies regardless of age, parity, and locality differences. Furthermore, the urban/rural women with different levels of parities who did not want to be pregnant were more educated than the urban/rural women who wanted pregnancies. Finally, the standardized regression coefficients, obtained in logistic regression, reveal that among urban women the desire for more children and parity are the first and second most significant independent variables differentiating between group A and group B. Among rural women, living children and the desire for more children were the first and second most important variables differentiating between group A and group B.     

Reduced reproductive function in wild baboons (Papio hamadryas anubis) related to natural consumption of the African black plum (Vitex doniana)

Several authors have suggested that the consumption of plant compounds may have direct effects on wild primate reproductive biology, but no studies have presented physiological evidence of such effects. Here, for two troops of olive baboons (Papio hamadryas anubis) at Gashaka-Gumti National Park, Nigeria, we show major seasonal increases in levels of fecal progesterone metabolites in females, and provide evidence that this is linked to the consumption of natural plant compounds. Increases in fecal progestogen excretion occurred seasonally in all females, in all reproductive states, including lactation. Detailed feeding data on the study animals showed that only one food species is consumed by both troops at the time of observed progestogen peaks, and at no other times of the year: the African black plum, Vitex doniana. Laboratory tests demonstrated the presence of high concentrations of progestogen-like compounds in V. doniana. Together with published findings linking the consumption of a related Vitex species (Vitex agnus castus) to increased progestogen levels in humans, our data suggest that natural consumption of V. doniana was a likely cause of the observed increases in progestogens. Levels of progestogen excretion in the study baboons during periods of V. doniana consumption are higher than those found during pregnancy, and prevent the expression of the sexual swelling, which is associated with ovulatory activity. As consortship and copulatory activity in baboons occur almost exclusively in the presence of a sexual swelling, V. doniana appears to act on cycling females as both a physiological contraceptive (simulating pregnancy in a similar way to some forms of the human contraceptive pill) and a social contraceptive (preventing sexual swelling, thus reducing association and copulation with males). The negative effects of V. doniana on reproduction may be counter-balanced by the wide-range of medicinal properties attributed to plants in this genus. This is the first time that physiological evidence has been presented of direct effects of plant consumption on the reproductive biology of wild primates.