Effect of family planning services on modern contraceptive method continuation in Vietnam

Access to and quality of services have increasingly been the focus of family planning programme managers, implementers and researchers in the developing world. In Vietnam, a country characterized by recent significant achievements in family planning, not much is known about the linkages between service accessibility and quality and contraceptive behaviour. Data for this study come from the Vietnam 1997 Demographic and Health Survey, with individual contraceptive use information recorded in the calendar section. Measures of access to and quality of services come from the Community/Health Facility Questionnaire, with key informant interviews and facility visits. The study focuses on the effects of the outreach programme and commune health centres on contraceptive method discontinuation for three modern, temporary methods: the IUD, oral pills and condoms. Longer travel time to commune health centres is found to be associated with significantly increased risks of first- and all-method discontinuation for any reason, while residence in communities with higher quality health centres is associated with significantly lower risks of method discontinuation. Access to and quality of the outreach programme are, in contrast, not significant determinants of method discontinuation for any reason. Similar results are found for first- and all-method discontinuation for service-related reasons. The effects of programmatic factors are more pronounced among older women and during the first three months of method use. This study provides evidence for the importance of family planning services for contraceptive method continuation in Vietnam. The results also highlight the need for a thorough evaluation of the family planning outreach programme in terms of its facilitation of women's continued use of contraception.     

Birds Do It. Bees Do It. So Why Not Single Women and Lesbians?

Infertile couples have come to take assisted reproductive technologies (ART) for granted. An increasing number of single women and lesbian couples also desire to have children and turn to ART, especially donor insemination, to fulfill this desire. While most married couples find that access to ART is limited primarily by the ability to pay, for single women and lesbian couples, the story may be much different. In the United States, they may find that doctors and infertility clinics view their desires as immoral and refuse to accept them as patients, although other doctors and clinics readily accept them. In most other countries, however, it is against the law for single women and lesbian couples to make use of ART, including donor insemination.
In this paper I will argue that marital status and sexual orientation should not serve as a barrier to accessing the world of reproductive medicine. I will base this conclusion on two arguments. First, that justice requires that we treat like cases alike. Just as we would not accept or reject patients for cardiac rehabilitation programs based on factors such as a history of poor eating habits, so too we should not look at nonmedical factors such as marital status when deciding whether to treat infertility. For the second justification for the conclusion of equal access to ART, I will examine the concept of the family. I will argue that it is morally acceptable for single women and lesbian couples to have children and to head families.     

Birds do it. Bees do it. So why not single women and lesbians?

Infertile couples have come to take assisted reproductive technologies (ART) for granted. An increasing number of single women and lesbian couples also desire to have children and turn to ART, especially donor insemination, to fulfill this desire. While most married couples find that access to ART is limited primarily by the ability to pay, for single women and lesbian couples, the story may be much different. In the United States, they may find that doctors and infertility clinics view their desires as immoral and refuse to accept them as patients, although other doctors and clinics readily accept them. In most other countries, however, it is against the law for single women and lesbian couples to make use of ART, including donor insemination.
In this paper I will argue that marital status and sexual orientation should not serve as a barrier to accessing the world of reproductive medicine. I will base this conclusion on two arguments. First, that justice requires that we treat like cases alike. Just as we would not accept or reject patients for cardiac rehabilitation programs based on factors such as a history of poor eating habits, so too we should not look at nonmedical factors such as marital status when deciding whether to treat infertility. For the second justification for the conclusion of equal access to ART, I will examine the concept of the family. I will argue that it is morally acceptable for single women and lesbian couples to have children and to head families.     

A physician's guide to discontinuing benzodiazepine therapy.

Practicing physicians need to have practical techniques to help patients who want to stop using benzodiazepines. I have developed three approaches that usually work. The first, and most widely applicable, is gradually reducing the dose without adding any other medicine. Failing this, use one of the following two approaches, occasionally combining them: switch to a longer-acting, cross-tolerant medication (usually clonazepam or phenobarbital) or use medications to suppress the withdrawal symptoms, usually carbamazepine, propranolol, or clonidine. If this fails, use inpatient detoxification. Chemically dependent patients, including those abusing alcohol and taking higher than recommended doses of sedative-hypnotics, require special care during discontinuation. Aftercare is important for all long-term benzodiazepine users if they are to remain drug-free and live relatively comfortable lives.     

“I Spent a Full Month Bleeding,I Thought I Was Going to Die…” A Qualitative Study of Experiences of Women Using Modern Contraception in Wakiso District,Uganda

Introduction

There is high unmet need for family planning (FP) in Uganda as well as high contraceptive discontinuation rates. These contribute to the high fertility rates that in part are due to unplanned pregnancies. There are gaps in knowledge about experiences that couples go through while using contraceptives in their lives. This study explored women’s experiences during the course of their contraceptive use.

Methods

We conducted a qualitative study involving 30 women who had used modern contraception for at least one year in Wakiso district, central Uganda. We used in-depth interviews to obtain their personal accounts. Index women were approached through health officers at four health centres in the district. All ethical approvals and informed consent were obtained. We used conventional content analysis; identifying codes through open coding, on which basis categories were developed and grouped into overarching themes.

Results

Women’s accounts were summarised in the following themes: negative experiences with modern contraceptive use, motivation to continue using FP in spite of these negative experiences, the role of influential people, and discontinuation of use. Negative accounts dominated the experiences of most women but they expressed strong desire to continue using modern contraception even amidst all challenges. Health workers emerged as the most influential people that played a vital role in women’s decisions.

Conclusion

Varied negative experiences with modern contraception and misperceptions exist amidst a determination to continue use. Partner engagement, health service strengthening to improve side effects management and health worker skills, and engaging older women that have successfully used contraception as community champions, are potential strategies to support women’s contraceptive decisions.     

Voluntary sterilization in Flanders

From 1966 to 1990 there was a marked rise in the use of voluntary sterilization in Flanders, followed by a fall in women under the age of 40. In the last three decades a remarkable change has occurred in the choice between male and female sterilization. Compared with many other European countries, sterilization of men and women is widely practised in Flanders. In 1996 40% of 40- to 44-year-old women underwent voluntarily sterilization or had voluntarily sterilized partners. Additionally, another 9% of these women were sterilized for medical reasons. Voluntarily sterilized couples are on average older than non-sterilized couples, and, obviously, consider their families to be complete. For couples with a complete family, parity is the most important predictor in the choice between sterilization and non-sterilization. Regularly practising Catholics undergo sterilization least. Also, highly educated couples are less likely to have a sterilization. Couples who ever experienced a contraceptive failure choose sterilization more. Voluntary sterilization has no substantial effect on the fertility of the population since the effect on the prevented numbers of both wanted and unwanted births appears to be small. However, if voluntary sterilization did not occur, differences in fertility within the population would probably increase. It is presumed that the popularity of voluntary sterilization in Flanders has passed its peak and that its use will decline in the near future.     

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.     

Concordance between partners in desired waiting time to birth for newlyweds in India

Examining waiting time to birth among newlywed couples is likely to provide insights into the desire for spacing births among newlywed husbands and wives. Data from the Indian National Family Health Survey of 2005-06 are used to examine the desired waiting time (DWT) to birth among newlywed couples. The dependent variable is spousal concordance on desired waiting times. Overall 65% of couples have concordant desired waiting times. Among discordant couples, wives were more likely to want to wait longer than their husbands. Couples from richer wealth quintiles were more likely than couples from the poorest quintile to have concordant desired waiting times. Muslims were less likely than Hindus to have concordant desires. There is a need for spacing contraceptive methods among newlyweds in India. This may have implications for the Indian Family Planning Programme, which to date has largely focused on sterilization. Programmes need to include newlywed husbands to promote use of spacing methods.     

Geographic distributions of homosporous ferns: does dispersal obscure evidence of vicariance?

The central problem in biogeography is that interactions between different processes result in the formation of historical patterns, such that it is difficult to discriminate the relative roles of vicariance and dispersal. Ferns are distributed by small wind-dispersed propagules that are produced in very large numbers and capable of dispersing thousands of kilometers. Thus, most taxon distributions in ferns are assumed to be a function of dispersal rather than vicariance. Here, we review some case examples that provide good evidence for vicariance and dispersal in ferns. We then ask whether dispersal is so extensive in ferns that vicariance is no longer detectable in most cases. Although we think that too few studies have been carried out to make generalizations at this stage, we outline the criteria for an effective research programme that can address this issue. Phylogenetic and distributional data are needed, not only because they are lacking in an evolutionarily important group of organisms, but also because data from ferns and other cryptogams are likely to be crucial in making broad biogeographic statements.     

Expected effects of mass screening policies on the frequency of cystic fibrosis homozygotes

We evaluated, by deterministic computer simulation, some effects of a screening programme for carriers of cystic fibrosis mutations. Two different selective regimes (heterozygote advantage and directional selection against recessive homozygotes) and three kinds of response to the screening were simulated. The curves describing the expected decline in the frequency of CF homozygotes allow one to predict some benefits of a screening campaign. In addition, it is shown that a strategy aimed at testing couples, rather than individuals, may become less expensive after only two generations of screening. The main source of uncertainty for a screening programme remains the selection mechanism, namely the existence of some sort of biological advantage for heterozygous carriers of CF mutations. Received: 11 March 1997 / Accepted: 15 May 1997     

In support of a compensation plan for vaccine-associated injuries. Infectious Diseases and Immunization Committee,Canadian Paediatric Society.

Between 1971 and 1973, 200 Dalkon Shield and 142 Gyne-T 200 intrauterine devices (IUDs) were inserted at the department of obstetrics and gynecology in a large urban hospital. In 1984 retrospective analysis of events associated with the use of these IUDs was done. Hospital and clinic charts were reviewed, and the women were contacted to obtain information on infertility and the outcome of pregnancy after discontinuation of IUD use. The rates of events leading to discontinuation of IUD use 2 years after insertion were similar in the two groups except for that of planned pregnancy, which was higher in the Dalkon Shield users (p less than 0.05). The rates of accidental pregnancy per 100 women were 3.8 for the Dalkon Shield users and 1 for the Gyne-T 200 users. The rates of pelvic inflammatory disease (PID) based on all cases of PID and follow-up information were similar in the two groups. There were no differences between the two groups in outcome of pregnancy with the IUD in situ or after expulsion or removal of the IUD because of planned pregnancy or other reasons. Infertility rates after discontinuation of IUD use were similar for the Dalkon Shield and Gyne-T 200 users. The results confirm the authors'' opinion that the Dalkon Shield and Gyne-T 200 IUDs are safe and effective methods of intrauterine contraception.     

Characteristics of users of traditional contraceptive methods in Bangladesh

Various national surveys suggest that the % of eligible couples in Bangladesh who are using traditional methods of contraception has been growing. This article presents detailed information on knowledge and use patterns of traditional methods and compares the use patterns of traditional and modern methods of contraception. The data are derived from the 1981 Contraceptive Prevalence Survey and information collected from a nationally representative sample of ever married women aged under 50, by way of field interviews using female interviewers. Quality of data was checked at different phases of the survey. Over 96% of the women reported that they knew at least 1 traditional method of contraception. The safe period was the most well known method (36.5%); about 30% reported knowledge of abstinence and 22% knew about withdrawal. Compared with modern methods, where knowledge declined with increased age, the knowledge of traditional methods shows no systematic pattern by age. Respondents with primary and higher education have higher knowledge of traditional methods than women who have never been to school. A similar pattern exists for employment status; non-Muslim women have consistently higher levels of knowledge than Muslim women. Data on patterns of use suggest that about 36% have used at least 1 contraceptive method, 15% having used traditional methods and 20.4% modern methods. The number of women who have used traditional methods increases from ages 20 to 44 and then declines. Use of traditional methods is relatively higher by the number of living children than by the number of children ever born. A similar pattern of association between background characteristics (education, employment and religion) and contraceptive knowledge is evident regarding level of use. Husband's level of education does not show any significant relationship with the use of traditional methods. The use rate of traditional methods was more than doubled among the women owning land compared to those having no land. The total current use rate of modern methods was higher among women aged 40-44 having relatively higher numbers of living children. As with current use, a positive relationship was observed between the socioeconomic variables and ever use. In general, it is concluded that socioeconomic variables played a dominant role in the decision of couples in choosing various methods of contraception. It is suggested that traditional methods still have an important role in family planning and that this should not be disregarded.     

Disagreement in spousal reports of current contraceptive use in sub-Saharan Africa

Contraceptive prevalence is a key variable estimated from Demographic and Health Surveys. But the prevalence estimated from reports of husbands differs widely from that estimated for wives. In this research, using data from six Demographic and Health Surveys of sub-Saharan Africa, reports from spouses in monogamous couples with no other reported sex partners in the recent period are examined. Agreement ranged from 47% to 82%, but among couples in which one or both reported use, the 'both' category represented less than half in all nations except Zimbabwe. Husbands generally had higher reports of condoms, periodic abstinence and pills but fewer reports of the IUD, injections and female sterilization. Either discussion of family planning with the spouse and/or higher socioeconomic status was associated with agreement in most of the surveys. Ambiguities in the survey question regarding current use need to be reduced, perhaps with an added probe question for non-permanent methods.     

Childlessness predicts helping of nieces and nephews in United States, 1910

The 'helpers at the nest' hypothesis suggests that individuals who are not currently reproducing often help kin by caretaking and thereby increase their inclusive fitness. Using a large scale historical dataset (Integrated Public Use Microdata Series sample of 1910; n=13,935), the hypothesis is tested that childless couples are more likely to fulfil such a role by taking care of a niece or nephew, but not a parent, than couples with children. Childless couples were significantly more likely to take care of a niece or nephew than couples with children. In contrast, couples with children and childless couples did not differ in caretaking of parents. Childless couples were also more likely to have more and younger nieces/nephews in their home than couples with children.     

Paternal effects on the human sex ratio at birth: evidence from interracial crosses

The effects of interracial crossing on the human sex ratio at birth were investigated using United States birth-certificate data for 1972-1979. The sex ratio was 1.059 for approximately 14 million singleton infants born to white couples, 1.033 for 2 million born to black couples, and 1.024 for 64,000 born to American Indian couples. Paternal and maternal race influences on the observed racial differences in sex ratio were analyzed using additional data on approximately 97,000 singleton infants born to white-black couples and 60,000 born to white-Indian couples. After adjustment for mother's race, white fathers had significantly more male offspring than did black fathers (ratio of sex ratios [RSR] = 1.027) and Indian fathers (RSR = 1.022). On the other hand, after adjustment for father's race, white mothers did not have more male offspring than did black mothers (RSR = 0.998) or Indian mothers (RSR = 1.009). The paternal-race effect persisted after adjustment for parental ages, education, birth order, and maternal marital status. The study shows that the observed racial differences in the sex ratio at birth are due to the effects of father's race and not the mother's. The study points to paternal determinants of the human sex ratio at fertilization and/or of the prenatal differential sex survival.     

Consistent condom use dynamics among sex workers in Central America: 1997-2000

The paper aims to provide evidence on consistent condom use dynamics among sex workers in Central America between 1997 and 2000, and to examine the most important predictors of use behaviour important for policy and programme interventions in the region. Data on 3500 sex workers, 1500 from 1997 and 2000 from the year 2000, were analysed. The samples represented sex workers in low socioeconomic neighbourhoods who met their clients at known sex establishments or by the roadside. Sex workers were more likely to have used condoms consistently in 2000 than in 1997 (Odds Ratio (OR) = 1.4, p < or = 0.05). Sex workers who discussed condoms with their partners or lovers used them consistently with all clients more than those who did not (OR = 1.3, p < or = 0.10). Knowledge of condom advantages had a positive influence on consistent use. Sex workers who reported using condoms to prevent pregnancy or STDs used them consistently with all clients more than those who did not (OR = 1.2, and 1.3 respectively, p < or = 0.10). The source of condoms is an important predictor of consistent condom use. Sex workers who bought condoms from health establishments or from brothels used them consistently more than those who did not (both OR = 1.3, p < or = 0.10, and p < or = 0.05, respectively). Self-efficacy had a positive effect on consistent condom use. Sex workers who reported that they would use condoms even if clients offered to pay more for unprotected sex used them consistently with all clients more than those who did not (OR = 18, p < or = 0.001). The findings suggest that having condom skill is positively related to condom use. Sex workers who had all four skills used condoms more consistently than those who had none (OR = 1.6, p < or = 0.01). In order to increase consistent condom use and avert more incidences of HIV/AIDS and other STIs, programme interventions need to use the most efficient way to provide quality information, and provide repeated training on condom negotiation and use skills to sex workers.     

Contraceptive failure: levels, trends and determinants in Matlab, Bangladesh

This study investigated the levels, trends and determinants of contraceptive use-failure in Matlab, Bangladesh, using a set of prospective data on 25,960 women of reproductive age. The data were extracted from the Record Keeping System (RKS) of Matlab for the period 1978-94. If there was any live birth during the use or within 7 months after the discontinuation of use, it was considered as a failure. The life table technique and hazard model were used as analytical tools. The results suggest that use-failure for pills, IUDs (TCu 200) and injectables and other temporary methods increased from 1978 to 1988, but began to decline after 1988. The cumulative probability of first-method failure within 1 year of method acceptance of the cohort of 1990-94 acceptors was 12.9% for pills, 2.0% for IUDs, 0.5% for injectables, 22.0% for condoms and 13.4% for 'other' methods (sampoon, foam, jelly and traditional methods). For pills, condoms and 'other' methods, the likelihood of failure declined with the duration of use; by contrast, the probability of an IUD failure increased over time, peaking at 3 years of use. The injectables maintained a low likelihood of failure regardless of the duration of use. The quality of Community Health Workers' (CHWs) performance was associated with the risk of failure of all temporary methods except condoms; women's background characteristics associated with failure varied by method. The effect of the quality of the CHWs' performance and the background variables on failure did not change much over time. It is felt that contraceptive failure deserves the serious attention of programme managers and policy makers to make the Bangladesh national family planning programme more successful.     

Structural dynamics of bacterial ribosomes: IV. Classification of ribosomes by subunit interaction

Previous studies in this series (M. Noll et al., 1973a,b; Noll & Noll, 1974) have established that in Escherichia coli the ability of subunits to form vacant 70 S ribosome couples at 10 mm-Mg²⁺ is a stringent condition for activity in the translation of natural messenger (R17 RNA). The present study examines the structural basis of subunit interaction. It is found that vacant ribosome couples prepared by various methods fall into two classes, “tight” couples and “loose” couples, that differ in the affinity of their subunits for each other. Detection and separation of the two particle species is possible by ultracentrifugation. When analyzed on sucrose gradients at 6 mm-Mg²⁺ and moderate speed (30,000 revs/min), tight couples sediment as undissociated 70 S ribosomes, whereas loose couples are completely dissociated and sediment as 30 S and 50 S subunits. At 15 mm-Mg²⁺ in the gradient, both species sediment as a 70S peak. At 10 mm-Mg²⁺ and 60,000 revs/min, two peaks (63 S and 55 S) are seen because the high hydrostatic pressure causes more pronounced dissociation of the loose than of the tight couples.Association is dependent on the state of each subunit. Removal of Mg²⁺ produces 30 S b-particles that are unable to associate with 50 S subunits unless reconverted to the 30 S a-form by thermal activation according to Zamir et al. (1971). In the dissociated state, 50 S subunits tend to change irreversibly to a 50 S b-modification that produces loose couples upon association with 30 S a-subunits. The 50 S a → 50 S b transition could not be related to breaks in 23 S RNA detectable by sedimentation analysis. However, mild treatment of 50 S a-subunits with RNase produces particles that associate with 30 S a-subunits to couples that are less stable than the loose couples resulting from a dissociation/association step.Fresh S-30 extracts contain only tight couples (approx. 80%) and subunits (approx. 20%). Our results suggest that loose couples are artefacts derived from tight couples by a structural or conformational modification.Interaction-free subunits that previously were found to form a primitive initiation complex with poly(U) and tRNA_Phe (Schreier & Noll, 1970,1971), and to be active in phenylalanine polymerization, are shown to consist of the b-form of each subunit.It is likely that conflicting results obtained in the study of the mechanism of initiation and other aspects of ribosome function are due to the lack of structural criteria required for standardizing the ribosome preparation used by different investigators. This study provides simple methods and criteria to classify and separate physically all ribosome and ribosome subunits that have been observed into well-defined classes of predictable activity.     

Eradication of cats (Felis catus) from subantarctic Macquarie Island

The feral Cat (Felis catus) population on Macquarie Island was targeted for eradication between 1996 and 2002, with 761 cats captured during this period. After 22 years of cat control from 1974 integrated with control programmes for other pests, effort intensified for 2 years before a dedicated eradication programme began in 1998. The primary knock‐down for the eradication used cage trapping and shooting, with most surviving cats captured with leg‐hold traps. A total of 6298 field days and 216 574 trap nights were recorded in this operation. Factors contributing to the success of the programme included extensive planning, increased staff numbers at critical times, better access to remote areas of the island, introduction of leg‐hold traps, sufficient operational funding and good collaboration between government agencies operating on the island. The programme would have benefited from earlier deployment of detector dogs and better posteradication monitoring of a broader range of native species impacted by cats. The successful eradication of cats from Macquarie Island, being the second largest achieved to date, provides valuable experience for cat eradication attempts on other large remote islands. This programme relied on ground‐based techniques with minimal use of poisons and provides possible options for sites where broad‐scale poisoning, or where aerial distribution of poisons, cannot be used.