bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality of Care Within the Indian Family Welfare Programme: A Review of Recent Evidence
Authors: Koenig Michael A. , Foo Gillian H.C. , Joshi Ketan
Published: December 2003

India's family planning program represents one of the earliest and most ambitious efforts in a developing country to address the issue of high fertility. Despite its more than four decades of existence, little is known concerning how the program is implemented at the field level, especially in relation to the quality of services provided. In this article, empirical evidence on the accessibility and quality of services provided through the Indian family planning program is reviewed and synthesized. The review highlights the serious and systemic shortcomings in quality of care that characterize the Indian program in such areas as restricted method choice, limited information provided to clients, poor technical standards, and low levels of follow‐up and continuity of care. The factors constraining higher service quality are subsequently reviewed, and the prospects for improving quality of care within the Indian program are assessed.
The Politics of Population Policy in the Islamic Republic of Iran
Authors: Hoodfar Homa , Assadpour Samad
Published: December 2003

The Islamic Republic of Iran arguably has one of the most successful family planning programs in the developing world. This success is all the more interesting for advocates of population programs because the political leaders of the Islamic regime were once strongly opposed to family planning. Indeed, after gaining power following the 1979 revolution, they were responsible for dismantling Iran's relatively new family planning program and introducing pronatalist policies. This article provides an account of the different phases of the population policy in Iran and examines the diverse elements that led politicoreligious leaders to revise their views about fertility control and to participate in creating a workable family planning program. The complex formal and informal strategies that the political experts, the media, the religious authorities, and the government of the Islamic Republic adopted in order to achieve this about‐face are described. The analysis is based on data collected by the first author during anthropological field research in 1993–96, by means of informal interviews with officials, with medical personnel, with family planning clients, and with religious leaders
Perceptions of the Risks of Sexual Activity and Their Consequences among Ugandan Adolescents
Authors: Hulton Louise A. , Cullen Rachel , Khalokho Symons Wamala
Published: December 2003

The principal aim of this study of adolescents in Mbale District, Uganda, is to provide program‐related information about their behavior, motivations, and perceptions of risk with regard to pregnancy and HIV transmission. Twelve single‐sex focus‐group discussions were conducted, six with young people aged 17–18 who were still attending school, and six with people of the same age who were not. The most important findings to emerge are that knowledge of safe‐sex behavior and reported behavior have little in common and that the fundamental barriers to behavioral change lie within the economic and sociocultural context that molds the sexual politics of youth. Young males' lack of responsibility for the outcomes of their behavior is identified as an important barrier to improved sexual health. The imperative to explore ways by which young women might achieve status and identity and acquire material resources by means not related to their sexuality is highlighted.
Premarital Fertility in Rural South Africa : A Challenge to Existing Population Policy
Authors: Garenne Michel , Tollman Stephen , Kahn Kathleen
Published: December 2003

The age pattern of fertility in a rural area of South Africa under demographic surveillance (Agincourt subdistrict) was investigated over the 1992–97 period. The total fertility rate (TFR) averaged 3.3 births per woman of reproductive age over the period, a major drop from earlier estimates in the same area (6.0 births in 1970–74). Age‐specific fertility rates showed an atypical bimodal pattern. They were decomposed into two components of similar magnitude: premarital fertility (among women aged 12–26) and marital fertility (among women aged 15–49). The decomposition revealed the two underlying modes: a mode of premarital fertility (among women aged 18–20) and a mode of marital fertility (among women aged 28–30). Premarital fertility accounted for 21 percent of all births and for 47 percent of births among women aged 12–26. This pattern of high premarital fertility appears to reflect a low incidence of contraceptive use before the first birth, especially among adolescents, a low prevalence of abortion, and a high contraceptive prevalence thereafter. This finding calls for a reorientation of the family planning policy, which until now has targeted married women and women who have been pregnant once, but has failed to address the contraceptive needs of young women before their first pregnancy, especially adolescents.
Screening and Syndromic Approaches to Identify Gonorrhea and Chlamydial Infection among Women
Authors: Sloan Nancy L. , Winikoff Beverly , Haberland Nicole , Coggins Christa , Elias Christopher
Published: December 2003

The standard diagnostic tools to identify sexually transmitted infections are often expensive and have laboratory and infrastructure requirements that make them unavailable to family planning and primary health‐care clinics in developing countries. Therefore, inexpensive, accessible tools that rely on symptoms, signs, and/or risk factors have been developed to identify and treat reproductive tract infections without the need for laboratory diagnostics. Studies were reviewed that used standard diagnostic tests to identify gonorrhea and cervical chlamydial infection among women and that provided adequate information about the usefulness of the tools for screening. Aggregation of the studies' results suggest that risk factors, algorithms, and risk scoring for syndromic management are poor indicators of gonorrhea and chlamydial infection in samples of both low and high prevalence and, consequently, are not effective mechanisms with which to identify or manage these conditions. The development and evaluation of other approaches to identify gonorrhea and chlamydial infections, including inexpensive and simple laboratory screening tools, periodic universal treatment, and other alternatives must be given priority.
Family Planning and Sexual Behavior in the Era of HIV/AIDS: The Case of Nakuru District, Kenya
Authors: Bauni Evasius K. , Jarabi Ben Obonyo
Published: December 2003

Recently, the prevalence of contraceptive use has increased in Kenya. The twin risks of unwanted pregnancy and HIV/AIDS infection remain central concerns of reproductive health programs. However, we do not know how sexually active men and women perceive these risks, nor the strategies they consider appropriate to cope with these risks, nor the difficulties they face in trying to adopt appropriate sexual behaviors to minimize them. This study seeks to provide insights into perceptions, coping strategies, and constraints in the changing behavior of sexually active people in Nakuru District, Kenya. Twelve focus‐group discussions were conducted, the results of which show that people in the study area consider the two risks to be serious problems, but that they neither use condoms within marriage nor refuse their partners sex even if they perceive a risk of acquiring HIV. These findings call for serious efforts toward fostering behavioral change in this area.
Potential Effects on Fertility and Child Health and Survival of Birth‐spacing Preferences in Sub‐Saharan Africa
Authors: Rafalitnanana Hantamalala , Westoff Charles F.
Published: December 2003

Using Demographic and Health Survey data from 20 sub‐Saharan African countries, this article compares the actual lengths of birth intervals to women's reported preferred lengths, and assesses the implications of the difference between the two for selected demographic and health indicators. The results show a clear pattern. In Comoros, Ghana, Kenya, Rwanda, and Zimbabwe, women prefer much longer birth intervals than those they actually have, compared with women in the other 15 countries studied. As a consequence, the potential effects of spacing preferences on the level of fertility and on the prevalences of short (less than 24 months) birth intervals and child malnutrition are greatest in the same five countries. The covariates of preferred birth‐interval lengths are also examined. An explanation is offered for this pattern, based on the observed sharp decline infertility recently experienced by these five “forerunners.” In general, women who know, approve of, discuss, and use family planning prefer longer intervals than do their counterparts. The policy and program relevance of these results is discussed.
An Assessment of DHS Maternal Mortality Indicators
Authors: Stanton Cynthia , Abderrahim Noureddine , Hill Kenneth
Published: December 2003

This study presents an assessment of the quality of data relating to maternal mortality collected in 14 Demographic and Health Surveys (DHS) for 13 countries that included a complete sibling history. Four aspects of data quality are considered: completeness of the data for reported events, evidence of omission in the reporting of events, plausibility of the pattern of sibling deaths, and sampling errors of the maternal mortality estimates. Although the data relating to reported events are complete for most variables, comparisons of sibling‐history‐based estimates of adult mortality for both males and females with other independent estimates suggest that sibling estimates are more likely to be underestimates than overestimates. The downward bias is probably greater for female mortality than for male mortality. The sampling errors associated with maternal mortality ratios are substantially larger than those associated with other frequently used DHS indicators. This lack of precision precludes the use of these data for trend analysis and has led to the recommendation that this DHS module not be used more than once every ten years in the same country.
The Role of Couple Negotiation in Unmet Need for Contraception and the Decision to Stop Childbearing in Uganda
Authors: Wolff Brent , Blanc Ann K. , Ssekamatte‐Ssebuliba John
Published: December 2003

This study uses survey and focus‐group data from the 1995–96 Negotiating Reproductive Outcomes study in Uganda to describe the nature of the decision to stop childbearing and to question the simplifying assumption of consensus decisionmaking implicit in much demographic research on unmet need. Negotiation is characterized in four stages, from normative precedent for decisionmaking to communication, disagreement, and conflict resolution. Indirect forms of communication between partners predominate, contributing to the tendency of both men and women to overestimate each other's demand for additional children. Partner opposition is found to cause a statistically significant increase in unmet need reported by women and a shift in contraceptive mix favoring use of traditional methods over modern methods. For women, partner opposition may account for as much as 20 percent of unmet need in urban areas, 12 percent in rural areas, and 15 percent overall.
Developing an Interactive STD‐prevention Program for Youth: Lessons from a North Indian Slum
Authors: Awasthi Shally , Nichter Mark , Pande V.K.
Published: December 2003

An intervention developed to teach young men in the urban slums ofLucknow, India, about sexually transmitted diseases is described in detail. This community‐based intervention was designed to impart core educational messages and to address preexisting ideas about sexual health and STD‐prevention practices among participants. Indicators of knowledge recorded before and after the intervention are presented and evaluated against the scores of a control group. Levels of sexual activity and factors associated with risky sex are discussed. The intervention was successful in raising the young men's awareness ofSTDs significantly in all areas except for the length of time that symptoms take to manifest following risky sex and the ineffectiveness of washing one's genitals after sex to avoid acquiring STDs. Lessons learned during the intervention are described as a means of informing future STD‐education programs, and issues requiring prompt attention are identified.
Implementing the Integration of Component Services for Reproductive Health
Authors: Mayhew Susannah H. , Lush Louisiana , Cleland John , Walt Gill
Published: December 2003

In the wake of the 1994 International Conference on Population and Development in Cairo, considerable activity has occurred both in national policymaking for reproductive health and in research on the implementation of the Cairo Program of Action. This report considers how effectively a key component of the Cairo agenda–integration of the management of sexually transmitted infections, including human immunodeficiency virus, with maternal and child health‐family planning services–has been implemented. Quantitative and qualitative data are used to illuminate the difficulties faced by implementers of reproductive health programs in Ghana, Kenya, South Africa, and Zambia. In these countries, clear evidence is found of a critical need to reexamine the continuing focus on family planning services and the nature of the processes by which managers implement reproductive health policies. Implications of findings for policy and program direction are discussed.
How Well Do Perceptions of Family Planning Service Quality Correspond to Objective Measures? Evidence from Tanzania
Authors: Speizer Ilene S. , Bollen Kenneth A.
Published: December 2003

This study examines the relationship between common objective measures of quality and perceptions of the quality of family planning facilities. Results of prior research indicate that such perceptions are an important determinant of contraceptive use in rural Tanzania. The data for this study are drawn from two surveys conducted in rural Tanzania. Three models are tested separately for women and for men. The important determinants of perceptions of quality among women and men are: perceived travel time to the facility, availability of immunizations, and availability of maternal and child health services. Additionally, the ratio of the number of staff to outpatients is important to men. The data explain a moderate amount of the variance in the quality measures, indicating that perceived quality is not fully predicted by common objective measures of quality. Future surveys of facility quality should develop objective measures to better predict the perceived quality, with the underlying goal of increasing contraceptive use.
The Potential Role of Contraception in Reducing Abortion
Authors: Bongaarts John , Westoff Charles F.
Published: December 2003

This study examines the potential role of further increases in contraceptive prevalence and effectiveness in reducing abortion rates. The model used in this analysis links the abortion rate to its direct determinants, including couples' reproductive preferences, the prevalence and effectiveness of contraceptive practice to implement these preferences, and the probability of undergoing an abortion to avoid an unintended birth when a contraceptive fails or is not used. An assessment of the tradeoff between contraception and abortion yields estimates of the decline in the total abortion rate that would result from an illustrative increase of 10 percentage points in prevalence. This effect varies among societies, primarily because the tendency to obtain an abortion after an unintended pregnancy varies. For example, in a population with an abortion probability of 0.5, a 10 percentage‐point increase in prevalence would avert approximately 0.45 abortions per woman, assuming contraception is 95 percent effective. If all unintended pregnancies were aborted, this effect would be three times larger. Eliminating all unintended pregnancies and subsequent abortions would require a rise in contraceptive prevalence to the level at which all fecund women who do not wish to become pregnant practice contraception that is 100 percent effective. A procedure is provided for estimating this “perfect” level of contraceptive prevalence.
Who's at Risk? Men's STD Experience and Condom Use in Southwest Nigeria
Authors: Messersmith Lisa J. , Kane Thomas T. , Odebiyi Adetanwa I. , Adewuyi Alfred A.
Published: December 2003

Many STD/HIV‐prevention programs worldwide assume that individuals' risk of acquiring sexually transmitted diseases, including HIV infection, is highest in the context of commercial sex. To address this assumption, research conducted in urban Southwest Nigeria combined qualitative and quantitative methods to examine men's sexual behavior, condom use, and STD experience in different types of sexual relationships (marital, casual, and commercial). Logistic regression analysis of survey data indicates that number of sexual partners and sex with sex workers are positively and significantly related to STD experience. Follow‐up in‐depth interviews with clients of sex workers indicate, however, that these men are actually more likely to report having contracted an STD from a casual sex partner than from a sex worker. Men are most uncertain about their vulnerability to STDs with casual partners. Men's condom use is highest in commercial sex, inconsistent in casual relationships, and lowest in marriage. STD/HIV‐prevention programs need to address the range of sexual relationships and the meanings and behaviors associated with them.
Trends and Determinants of Contraceptive Use in Rakai District, Uganda, 1995–98
Authors: Lutalo Thomas , Kidugavu Medi , Wawer Maria J. , Serwadda David , Zabin Laurie Schwab , Gray Ronald H.
Published: December 2003

A prospective study conducted between 1995 and 1998 assessed trends in contraceptive use in rural Rakai District, Uganda. Over a period of 30 months, women's use of modern contraceptives increased significantly from 11 percent to 20 percent. Male condom use increased from 10 percent to 17 percent. The prevalence of pregnancy among sexually active women 15–49 declined significantly from 15 percent to 13 percent. Women practicing family planning for pregnancy prevention were predominantly in the 20–39‐year age group, married, better educated, and had higher parity than others, whereas women or men adopting condoms were predominantly young, unmarried, and better educated. Condom use was particularly high among individuals reporting multiple sexual partners or extramarital relationships. Contraceptive use was higher among women who desired fewer children, among those who wished to space or terminate childbearing, and among women with previous experience of unwanted births or abortions. Self‐perception of HIV risk increased condom use, but HIV testing and counseling had only modest effects. Contraception for pregnancy prevention and for HIV/STD prophylaxis are complementary.
Sexual Initiation and Contraceptive Use Among Adolescent Women in Northeast Brazil
Authors: Gupta Neeru
Published: December 2003

To estimate trends and determinants of sexual initiation and contraceptive use among adolescent women in Northeast Brazil, multivariate logistic hazard models are used that draw on data from three Demographic and Health Surveys conducted there between 1986 and 1996. Educational attainment is among the variables found to be associated most consistently with differential risk of engaging in first intercourse during adolescence, including premarital intercourse, and of contraceptive use during sexual initiation. Greater frequency of attending religious services and greater exposure to television are also associated with lower rates of sexual initiation and higher use of contraceptives. Seemingly diminishing returns of education on delayed sexual activity may help explain, in part, observed increases in the absolute level of adolescent sexual experience across survey periods, however. Multilevel modeling techniques pointing to the existence of cluster‐level random variances underline the need for further research into community influences on individual sexual activity.
The First Generation to Control Family Size: A Microstudy of the Causes of Fertility Decline in a Rural Area of Bangladesh
Authors: Caldwell Bruce , Barkat‐e‐Khuda
Published: December 2003

In Bangladesh, the total fertility rate declined from more than six children per woman of reproductive age in 1980 to 3.3 children per woman in 1996. Much discussion has ensued about the circumstances responsible for this decline and, in particular, about the contribution made by the national family planning program. For this study, qualitative interviews were conducted with 67 women concerning the factors influencing their reproductive behavior. The participants, residents of a rural area in southwestern Bangladesh, consisted of two groups: women who were currently practicing family planning and women who had never practiced or had not done so for at least four years. The findings suggest that the family planning program has played an important role in reducing family size, but also indicate that economic and social changes, and especially growing aspirations (particularly for a life outside agriculture) have combined with changes in the nature of family decisionmaking to make couples more receptive to the idea of family planning.
Researching Domestic Violence Against Women: Methodological and Ethical Considerations
Authors: Ellsberg Mary , Heise Lori , Peña Rodolfo , Agurto Sonia , Winkvist Anna
Published: December 2003

The results of three population‐based studies on violence against women in Nicaragua are compared in this article. Two of the studies were regional in scope (Leon and Managua) and focused specifically on women's experiences of violence, whereas the third study was a Demographic and Health Survey (DHS) conducted with a nationally representative sample of women. The lifetime prevalence estimates for women's undergoing physical violence from a partner were significantly higher in the Leon study (52 percent) and Managua study (69 percent), compared with that given in the DHS (28 percent). Possible explanations for the differences are examined through pooled multivariate logistic regression analysis, as well as analysis ofsix focus‐group discussions cairied out with field‐workers and staff from the three studies. The most important differences that were found concerned ethical and safety procedures and the interview setting. The results indicate that prevalence estimates for violence are highly sensitive to methodological factors, and that underreporting is a significant threat to validity.
Childbearing in Five Arab Countries
Authors: Eltigani Eltigani E.
Published: December 2003

The life‐table technique is used in this study to describe childbearing patterns in five Arab countries (Algeria, Egypt, Morocco, Sudan, and Yemen). Two summary measures are estimated: the cumulative proportion of women of a given parity having a subsequent birth within 60 months of the previous birth (quintum), and the median length of the interval between successive births. The analysis indicates that in Yemen (where the total fertility rate exceeds seven children per woman of reproductive age), women begin childbearing at a relatively early age and a large proportion of ever‐manied women reach high parity at a relatively fast pace. Morocco and Egypt (with TFRs of 3.3 and 3.8 children per woman, respectively) are characterized by delay in the onset of childbearing, a slow pace of childbearing, and a smaller proportion of ever‐married women reaching high parity. In Algeria and Sudan (with TFRs of 4.4 and 4.6 children), delay in the onset of childbearing plays a larger role infertility reduction than do the tempo or the quantum of childbearing.
Is Fertility Declining in Benin?
Authors: Capo‐chichi Virgile , Juarez Fatima
Published: December 2003

This study analyzes reproductive changes in Benin, a West African country with high fertility and low prevalence of use of modern contraceptive methods, using a combination of quantitative and qualitative approaches. Findings indicate that an irreversible fortuity transition has started as the result of an emerging pattern of birth limitation and continued desire for the traditional long birth intervals. The data suggest that changes in childhood mortality in combination with an increase in women's education, although modest, have created a demand for fertility control among women; that induced abortion may be one of the means through which such demand is being met, particularly in urban areas; and that the economic crisis of the 1980s was the main catalyst that precipitated the onset of transition. Changes in reproductive preferences and practice suggest a diffusion process, from urban and more educated women to rural and less‐educated ones.
The Role of Changes in Contraceptive Use in the Decline of Induced Abortion in Turkey
Authors: Senlet Pinar , Curtis Siân L. , Mathis Jill , Raggers Han
Published: December 2003

Tlie induced abortion rate in Turkey declined from a peak of 4.5 abortions per 100 women in 1988 to 2.4 in 1998. This study examines the extent to which the decline in abortion in Turkey can be attributed to increased use of modern contraceptives. Trends in induced abortion rates and in contraceptive use are examined among Turkish women together with fertility preferences, changes in the contraceptive behavior associated with abortion, and changes in the propensity to abort unwanted pregnancies. The analysis includes a number of simulations that examine what abortion levels might be in different contraceptive‐use scenarios. Results indicate that the decline in abortion is due to a decrease in the number of abortions associated with traditional method failure. This decrease is related to three factors: a shift from traditional method use to modern method use, a decline in the traditional method failure rate, and a decline in the proportion of pregnancies resulting from traditional method failures that are aborted.
Correlates of Sexual Activity and Condom Use among Secondary‐school Students in Urban Peru
Authors: Magnani Robert J. , Seiber Eric E. , Gutierrez Emily Zielinski , Vereau Dorina
Published: December 2003

Recent data indicate that adolescent fertility rates in Peru remain high and that Peruvian adolescents and young adults account for a disproportionate share of new HIV infections. The present study was undertaken to identify key risk and protective factors for early sexual activity and unprotected sex among secondai‐y‐school students in nine large cities in Peru. Survey data from 6,962 students aged 13–18 are consistent with existing research in indicating that behaviors of Peruvian youth are influenced in important ways by many factors. In the present study, these included region of residence, family economic position, family structure, working for pay, peei‐ behaviors, and self‐esteem. Knowledge of pregnancy and of the risks of acquiring sexually transmitted diseases and of the means of avoiding both did not, however, differentiate risk‐takers from non‐risk‐takers. The study findings suggest a need fen‐ adolescent health programs to broaden their focus beyond the immediate proximate determinants of behavior, such as sexual and reproductive health knowledge and access to contraceptives, and also to target some of the key contextual factors influencing adolescent behavior.
Sterilization and Financial Penalties Imposed on Registered Peasant Couples, Hebei Province, China
Authors: Cooney Rosemary Santana , Li Jiali
Published: December 2003

Using fertility survey data from the 1980s for registered Han peasant couples in Hebei Province, this study examines whether China's family planning policy reflects couples' voluntary compliance with policy regulations, their coercion by means of government sanctions, or a combination of both. Three family planning regulations are considered: birth‐quota status, contraceptive use, and length of prior birth interval. The results of the study provide support for both compliance and sanction perspectives and suggest that by the late 1980s, the state was less willing than it had been previously to negotiate with couples who had had three children. Evidence is found of cooperation between couples and the state to ensure that each family had at least one son.
Obstacles to Contraceptive Use in Pakistan: A Study in Punjab
Authors: Casterline John B. , Sathar Zeba A. , ul Haque Minhaj
Published: December 2003

The principal aim of this study is to assess the strength in Pakistan of a set of hypothesized obstacles to practicing contraception. Survey data are analyzed that were collected in Punjab province in 1996 and that contain unusually detailed measurement of various perceived costs of practicing contraception, as well as focused measurement of fertility motivation. The framework guiding the research specifies six major obstacles to contraceptive use: the strength of motivation to avoid pregnancy, awareness and knowledge of contraception, the social and cultural acceptability of contraception, perceptions of the husband's preferences and attitudes, health concerns, and perceived access to services. Net effects of each obstacle are estimated through structural equation modeling of the intention to practice contraception in the near future, in which the six obstacles are treated as latent variables. The estimates indicate that the two principal obstacles to using a contraceptive are the woman's perception that such behavior would conflict with her husband's fertility preferences and his attitudes toward family planning and her perception of the social or cultural unacceptability of contraception. The results confirm the value of taking contraceptive costs seriously, and, in particular, of attempting to measure these costs in empirical research on family planning.
Husbands' and Wives' Reports of Contraceptive Use
Authors: Becker Stan , Costenbader Elizabeth
Published: December 2003

Many Demographic and Health Surveys (DHS) in the past decade have queried husbands and wives about their current contraceptive use. In this study, couples' concurrence on use and method used is compared by means of data from 23 countries, mostly in sub‐Saharan Africa. Husbands report higher levels of use than do their wives in every country studied, with ranges from 2 percent higher (Brazil) to 150 percent higher (Mali). Many of the discrepancies are the result of husbands' sole reports of periodic abstinence and condom use. Couples with polygynous husbands show less concurrence than do monogamous couples, although the majority of these differences could result from a data‐collection problem. Monogamous couples in which one or both spouses reported having extramarital sex partners show less concurrence than do monogamous couples reporting no other partners. Problems of validity of both husbands' and wives' reports are discerned, and in the few instances where a direct comparison is possible, wives' reports are shown to have greater validity. Logistic regression results show that spousal discussion about family planning and greater female education are consistent predictors of concurrence.
Bargaining Power Within Couples and Use of Prenatal and Delivery Care in Indonesia
Authors: Beegle Kathleen , Frankenberg Elizabeth , Thomas Duncan
Published: December 2003

Indonesian women's power relative to that of their husbands is examined to determine how it affects use of prenatal and delivery care. Holding household resources constant, a woman's control over economic resources affects the couple's decisionmaking. Compared with a woman with no assets that she perceives as being her own, a woman with some share of household assets influences reproductive health decisions. Evidence suggests that her influence on service use also varies if a woman is better educated than her husband, comes from a background of higher social status than her husband's, or if her father is better educated than her father‐in‐law. Therefore, both economic and social dimensions of the distribution of power between spouses influence use of services, and conceptualizing power as multidimensional is useful for understanding couples' behavior.
Adolescent Pregnancy and Parenthood in South Africa
Authors: Kaufman Carol E. , de Wet Thea , Stadler Jonathan
Published: December 2003

South Africa's total fertility rate is estimated to be one of the lowest in sub‐Saharan Africa, fewer than three births per woman nationally and declining. At the same time, adolescent childbearing levels remain high: More than 30 percent of 19‐year‐old girls are reported to have given birth at least once. Evidence from focus‐group discussions conducted in urban and rural areas in South Africa with young black women and men, and with the parents of teenage mothers, is used to consider the experience of early parenthood, including the role of paternity, education, work opportunities, and subsequent fertility. In South Africa, in contrast to many other settings, teenage mothers may return to school once they have given birth, and this opportunity is strongly related to a long delay before the birth of a second child. Educated girls also tend to bring more bridewealth, which may encourage parents to support their daughters' schooling, and perhaps their return to school following childbirth. The support of the child, however, is often subject to paternal recognition and. commitment, even though boys are unwilling to admit paternity because it jeopardizes their educational and employment opportunities.
Husband—Wife Survey Responses in Malawi
Authors: Miller Kate , Msiyaphazi Zulu Eliya , Cotts Watkins Susan
Published: December 2003

Previous efforts by demographers to describe and explain spousal differences in reporting about family planning behavior liave focused on individual attributes that are assumed to be related to the practice of contraception. This study extends that research by documenting spousal disagreement on a range of issues—household items, livestock, children, and spousal communication about fertility, family planning, and AIDS. Using data from a 1998 study of 585 monogamous couples in rural Malawi, the analysis identifies a systematic gender component to reporting: For many of the survey questions considered, when spouses disagree, husbands are more likely to say “yes” and wives “no.” The findings are interpreted in terms of gendered strategies in the interview process.
The Effect of Power in Sexual Relationships on Sexual and Reproductive Health: An Examination of the Evidence
Authors: Blanc Ann K.
Published: December 2003

This article reviews what has been learned to date about the role of gender‐based power in sexual relationships in determining sexual and reproductive health outcomes. A framework for assessing the relationship between power relations and reproductive health is outlined and measurement issues are critically discussed. A summary is included of the main types of intervention approaches that have been implemented, as are a discussion of the programmatic, methodological, and ethical implications of the findings and recommendations for further experimentation and research. Although many challenges remain, results to date suggest that when the role of gender‐based power is made an integral feature of sexual and reproductive health programs, there is a considerable payoff for both women and men.
The Link Between Postnatal Abstinence and Extramarital Sex in Cote d'lvoire
Authors: Ali Mohamed M. , Cleland John G.
Published: December 2003

Whether the link, found in Benin, between postnatal abstinence and husbands' extramarital contacts can be generalized to other West African countries is assessed in this study. Data from the 1994 Demographic and Health Survey, Cote d'lvoire, obtained from monogamous husbands concerning their extramarital sexual behavior in the two months preceding the survey were linked to data reported by wives concerning postnatal abstinence over the same time period. Logistic regression was applied to assess the link between these two factors, net of the effects of possible confounders. A significant effect of postnatal abstinence on the probability that the husband reported at least one extramarital partner was found. Unprotected extramarital sex was two times more common among men who observed conjugal abstinence than it was among other men. Other predictors of extramarital sex were urban‐rural residence, region, education, and whether or not husband and wife had the same religious affiliation. Because condom use is low in this population, the protective effect of marital abstinence is offset by an increased probability that husbands will seek extramarital partners during the postpartum period. The results confirm the earlier findings for Benin and can likely be generalized to most of West Africa.
Implications for Evaluating the Impact of Family Planning Programs with a Reproductive Health Orientation
Authors: Jain Anrudh
Published: December 2003

In 1994, Jain and Bruce proposed an index—HARI, an acronym for Helping Individuals Achieve their Reproductive Intentions—to measure success or failure of family planning programs with a reproductive health orientation. HARI applies the principle of individual rights and well‐being to the assessment of these programs. The index measures two components: the achievement of an individual's reproductive intentions and the avoidance of severe reproductive health problems associated with an individual's efforts to achieve her stated reproductive intentions. A family planning program can be deemed successful if an individual is able to avoid having an unintended pregnancy (or is able to have a wanted child) within the stipulated period and if she experiences no severe reproductive health problems in the process. If these conditions are not met, the program could be deemed a failure. The HARI index has not yet been applied infield conditions. This report illustrates the procedure for estimating HARI by using data from a panel survey conducted in Peru. It discusses the usefulness and limitations of the index in assessing the success or failure of a family planning program with a reproductive health orientation.
Impact of an Integrated Adolescent Reproductive Health Program in Brazil
Authors: Magnani Robert J. , Gaffikin Lynne , de Aquino Estela Maria Leão , Seiber Eric E. , de Conceição Chagas Almeida Maria , Lipovsek Varja
Published: December 2003

An impact evaluation of an integrated school‐ and health‐clinic‐based adolescent reproductive health initiative was undertaken by the State Secretariats of Health and Education in Bahia, Brazil during 1997–99. The project was initiated in response to continued high pregnancy rates among adolescents and growing numbers of new HIV infections among young adults. It sought to promote responsible sexual and health‐seeking behaviors among public secondary‐school students, including the use of public health clinics. The study design included a matched control group used to measure project impact. The findings indicate that the project was successful in increasing the flow of sexual and reproductive health information to secondary‐school students and that it had an impact on adolescents' intentions to use public health clinics in the future. No effects on sexual or contraceptive‐use behaviors or on use of public clinics were observed, however. Client exit‐interview data from a subset of project clinics indicate that adolescents who use clinic‐based services are overwhelmingly female and considerably older on average and much more likely ever to have been pregnant than are adolescents in the target population for the project.
Consistency Between Survey and Interview Data Concerning Pregnancy Wantedness in the Philippines
Authors: Williams Lindy , Sobieszczyk Teresa , Perez Aurora E.
Published: December 2003

Through a comparison of survey and in‐depth interview data reported by a small sample of Filipino women and men, standard survey questions and the standard conceptualizations of pregnancy wantedness are assessed to determine whether they capture respondents' attitudes toward pregnancies and their timing in two areas in the Philippines. The study reveals that more than two‐thirds of respondents were completely consistent in their survey and interview responses. Consistency was higher for women than for men, and it improved when a dichotomous measure (intended/unintended) was used rather than a more detailed variable that distinguished between intended, mistimed, and unwanted pregnancies. To the extent that the two data sources disagree, the interview transcripts suggest two possible reasons for inconsistent reports: deference to a spouse's perceived attitude or the respondent's ambivalence toward or ready acceptance of an unintended pregnancy.
Disobedient Distributors: Street‐level Bureaucrats and Would‐be Patrons in Community‐based Family Planning Programs in Rural Kenya
Authors: Kaler Amy , Watkins Susan Cotts
Published: December 2003

The implementation of social welfare programs, including family planning programs, is strongly conditioned by the needs, desires, and agendas of those who carry them out, known as “street‐level bureaucrats.” In this study, the strategies of CBD agents in western Kenya are examined in order to understand how they use their job as a means to achieve their own personal goals. The concept of clientelism, borrowed from the field of political science, can help to explain what the CBD agents are trying to achieve for themselves in their communities, at the same time as they promote the use of contraceptive pills and injections. CBD agents are concerned with building up their own stocks of prestige and respect from their community members, while avoiding blame for any possible negative outcomes of family planning.
Premarital Sex, Schoolgirl Pregnancy, and School Quality in Rural Kenya
Authors: Mensch Barbara S. , Clark Wesley H. , Lloyd Cynthia B. , Erulkar Annabel S.
Published: December 2003

Using data from nearly 600 adolescents aged 12–19 in combination with data collected from 33 primary schools that the adolescents attended, this report explores whether certain aspects of the school environment affect the initiation of premarital sex among girls and boys in three districts of Kenya. The results suggest that, although neither the school nor the home appears to influence whether boys engage in sex prior to marriage, for girls, a school characterized by a gender‐neutral atmosphere appears to reduce the risk of their engaging in premarital sex. Furthermore, although policymakers in Kenya are clearly concerned with the problem of “schoolgirl pregnancy,” the data indicate that in this sample, pregnancy is not the primary reason that girls leave school.
A Client‐centered Approach to Family Planning: The Davao Project
Authors: Costello Marilou , Lacuesta Marlina , RamaRao Saumya , Jain Anrudh
Published: December 2003

The reproductive health approach to family planning shifts the focus of service provision from macro‐level demographic objectives to meeting clients' needs. Little field experience exists to date, however, to indicate how to implement this approach. This study describes afield project in Davao del Norte and Compostela Valley provinces in the Philippines that implemented the reproductive health approach on a quasi‐experimental basis. The intervention was designed to address clients' self‐defined reproductive needs by providing them with relevant and accurate information and services of good quality. It consisted of two components: Providers were trained in information exchange at fixed clinics, and supervisors were trained in facilitative supervision. The results presented here indicate that the client‐centered intervention was successful in enhancing service providers' knowledge and improving the content of information exchange between providers and clients. One provincial health officer has expanded the intervention throughout his province, while other provinces are interested in duplicating the model.
Organizing a Public‐sector Vasectomy Program in Brazil
Authors: Penteado Luis Guilherme , Cabral Francisco , Díaz Margarita , Díaz Juan , Ghiron Laura , Simmons Ruth
Published: December 2003

Although models of high‐quality family planning services for men exist in Latin America, few if any have been organized within the complex and resource‐constrained national public health systems. This study provides evidence from the Santa Barbara project in southern Brazil showing how vasectomy was introduced into the municipal health system. It demonstrates that once the necessary operational and quality‐of‐care improvements were in place, and sufficient political and technical support existed to proceed, it was possible to establish low‐cost, well‐used, and sustainable vasectomy services free of charge. The findings show that careful attention to the development of strong technical competence and an informed choice process resulted in high user satisfaction. Focus‐group discussions with men who underwent vasectomy indicate that they had no objection to being served in the context of a women's health center and that they act as opinion leaders who draw an increasing clientele to the service.
Changes in Contraceptive Use in Bulgaria, 1995–2000
Authors: Carlson Elwood , Lamb Vicki
Published: December 2003

Comparison of results from national surveys conducted in Bulgaria in 1995 and 2000 reveal little overall change in use of modern contraceptives. Dramatic increases occurred, however, among women younger than 25 who entered their reproductive period after the end of the state socialist period. This finding suggests that contraceptive gains in the country will come largely as a cohort‐replacement process. From these data, no separate program impact appears for special clinics established to provide direct, subsidized delivery of modern contraceptives to women in selected cities. The special clinics opened in cities where contraceptive use was already above the national average. During these five years, other cities lacking special clinics managed to gain in prevalence of modern contraceptive use, leaving a relatively homogenous urban‐rural difference in levels of use throughout the country.
An Evaluation of the “Entre Nous Jeunes” Peer—educator Program for Adolescents in Cameroon
Authors: Speizer Ilene S. , Tambashe B. Oleko , Tegang Simon‐Pierre
Published: December 2003

A quasi‐experimental design is used in this study to evaluate the “Entre Nous Jeunes” peer‐educator program to promote STI/HlV‐preventive behaviors in Nkongsamba, Cameroon. The main objective of the study is to assess whether the young people exposed to a peer educator gained greater knowledge and practiced more protective behaviors than did those in the control community and those who were not exposed. During the 18‐month intervention period, the peer educators were able to reach a large number of young people, specifically those who were sexually experienced and in need of reproductive health information. Multivariate analyses indicate that contact with a peer educator is statistically significantly associated with greater spontaneous knowledge of modern contraception, the symptoms of sexually transmitted infections, and greater use of modern contraceptives, including the condom. In the absence of a peer‐education program, current contraceptive use in the intervention community would have been significantly lower.