Traditional supports and contemporary disrupters of high fertility desires in sub-Saharan Africa: a scoping review.

RATIONALE: The desired number of children is markedly higher in Sub-Saharan Africa (SSA) than in other major regions. Efforts to understand how and why these desires are generated and maintained have yielded a broad research literature. Yet there is no full picture of the range of contextual, cultural, and economic factors that support and disrupt high fertility desires. OBJECTIVE: This scoping review synthesizes thirty years of research on the determinants of fertility desires in SSA to better understand what factors underlie men and women's stated fertility desires and how they weigh the costs and benefits of having (more) children. METHOD: We identified and screened 9863 studies published from 1990 to 2021 from 18 social science, demographic, and health databases. We appraised determinants of fertility desires from 258 studies that met inclusion criteria according to their roles as traditional supports or contemporary disrupters of high fertility desires. RESULTS: We identified 31 determinants of high fertility desires, which we organized into six overarching themes: economy and costs; marriage; the influence of others; education and status; health and mortality; and demographic predictors. For each theme, we summarize ways in which the determinants both support and disrupt high fertility desires. We find that high fertility remains desirable in many regions of sub-Saharan Africa but contemporary disrupters, such as the economic situations and increases to family planning and education, cause individuals to decrease their desired fertility with such decreases often viewed as a temporary adjustment to temporary conditions. Most included studies were quantitative, cross-sectional, and based on survey data. CONCLUSION: This review demonstrates how traditionally supportive and contemporary disruptive forces simultaneously influence fertility desires in sub-Saharan Africa. Future studies analyzing fertility desires in sub-Saharan Africa should be informed by the lived experiences of men and women in this region, with qualitative and longitudinal studies prioritized.

In sub-Saharan Africa, both men and women continue to desire large numbers of children in contrast to most regions of the world where the desired number of children is near or below replacement level (around 2.0 children per couple). We conducted a comprehensive review of the existing research on the sources and drivers of the persistently high desired fertility in sub-Saharan Africa. Based on the review, 258 studies were included in this analysis. Several factors that influence fertility desires among men and women in this population were identified. We categorized them as either traditional supports (factors that have historically supported and promoted high fertility desires) or contemporary disrupters (factors that have more recently inhibited or discouraged high fertility desires). Although fertility desires are shaped by a wide range of factors that vary based on specific country and population, several overarching conclusions were clear. Contemporary changes in the economy and family have caused individuals to shift their fertility desires downward, and this shift is often viewed as a temporary adjustment to temporary conditions. Increased autonomy and formal schooling of women and availability of family planning can help position women to implement lower fertility desires. There is a need for more longitudinal research in this region to better understand how fertility desires may change over a person's life, and for more qualitative studies that allow people to describe and explain their lives and fertility desires more directly in ways that allow for uncertainty and ambiguity.

Women's beliefs about methods and contraceptive discontinuation: Results from a prospective study from Nairobi and Homa Bay counties in Kenya.

Background: Rates of contraceptive discontinuation are high in many low and middle countries contributing to unmet need for contraception and other adverse reproductive health outcomes. Few studies have investigated how women's beliefs about methods and strength of fertility preferences affect discontinuation rates. This study examines this question using primary data collected in Nairobi and Homa Bay counties in Kenya. Methods: We used data from two rounds of a longitudinal study of married women ages 15-39 years (2,812 and 2,424 women from Nairobi and Homa Bay respectively at round 1). Information on fertility preferences, past and current contraceptive behavior, and method-related beliefs about six modern contraceptive methods were collected, along with a monthly calendar of contraceptive use between the two interviews. The analysis focused on discontinuation of the two most commonly used methods in both sites, injectables and implants. We carry out competing risk survival analysis to identify which method related beliefs predict discontinuation among women using at the first round. Results: The percentages of episodes discontinued in the 12 months between the two rounds was 36%, with a higher rate of discontinuation in Homa Bay (43%) than in the Nairobi slums (32%) and higher for injectables than implants. Method related concerns and side effects were the major self-reported reasons for discontinuation in both sites. The competing risk survival analysis showed that the probability of method related discontinuation of implants and injectables was significantly lower among respondents who believed that the methods do not cause serious health problems (SHR = 0.78, 95% CI: 0.62-0.98), do not interfere with regular menses (SHR = 0.76, 95% CI: 0.61-0.95) and do not cause unpleasant side effects (SHR = 0.72, 95% CI 0.56-0.89). By contrast, there were no net effects of three method related beliefs that are commonly cited as obstacles to contraceptive use in African societies: safety for long-term use, ability to have children after stopping the method, and the approval of the husband. Conclusion: This study is unique in its examination of the effect of method-specific beliefs on subsequent discontinuation for a method-related reason, using a longitudinal design. The single most important result is that concerns about serious health problems, which are largely unjustified and only moderately associated with beliefs about side effects, are a significant influence on discontinuation. The negative results for other beliefs show that the determinants of discontinuation differ from the determinants of method adoption and method choice.

Alignment between Desires and Outcomes among Women Wanting to Avoid Pregnancy: A Global Comparative Study of "Conditional" Unintended Pregnancy Rates.

Since childbearing desires, and trends in these desires, differ across populations, the inclusion of women who want to become pregnant in the denominator for unintended pregnancy rates complicates interpretation of intercountry differences and trends over time. To address this limitation, we propose a rate that is the ratio of the number of unintended pregnancies to the number of women wanting to avoid pregnancy; we term these conditional rates. We computed conditional unintended pregnancy rates for five-year periods from 1990 to 2019. In 2015-2019, these conditional rates per 1,000 women per year wanting to avoid pregnancy ranged from 35 in Western Europe to 258 in Middle Africa. Rates with all women of reproductive age in the denominator have concealed stark global disparities in the ability of women to avoid unintended pregnancies, and they have understated progress in regions where the fraction of women wanting to avoid pregnancy has increased.

Factors associated with never-use of long-acting reversible contraception among adult reproductive-aged women in Ohio.

BACKGROUND: The number of women using long-acting reversible contraception (LARC)-intrauterine devices (IUDs) and implants-is increasing and 14% of contraceptive users in the United States adopt LARC. We examined correlates of LARC never-use in a population-based survey of reproductive-aged women in Ohio. METHODS: We analyzed data from the 2018-19 Ohio Survey of Women. We examined the prevalence of LARC never-use and reasons for never-use among ever users of contraception (N = 2388). Using Poisson regression to generate prevalence ratios (PRs), we examined associations between selected correlates (demographic factors, healthcare access/quality measures, and religious/political views) and LARC never-use. RESULTS: Most Ohio women (74%) had never used LARC. Commonly reported reasons for not using an IUD or an implant were preferring a different method (46% and 45%, respectively), not wanting an object inside their body (45% and 43%), side effect concerns (39% and 33%), insertion/removal concerns (31% and 25%), and unfamiliarity (13% and 20%). Conservative political views (PR: 1.12, 95% confidence interval [CI]: 1.04-1.22), pro-life affiliation (PR: 1.11, 95% CI: 1.02-1.20), placing high importance on religion in daily life (PR: 1.15, 95% CI: 1.06-1.26), and being non-Hispanic white as compared to non-Hispanic Black (PR: 1.20, 95% CI: 1.02-1.41) were significantly associated with LARC never-use. Findings were generally similar for models analyzing IUD and implant never-use separately. CONCLUSIONS: Among ever-users of contraception, LARC never-use was associated with having conservative political views, being religious, and having a pro-life affiliation. Except for race/ethnicity, demographic and healthcare measures were not associated with LARC never-use among women in Ohio.

Fertility Preferences and Contraceptive Change in Low- and Middle-Income Countries.

The past four decades have witnessed an enormous increase in modern contraception in most low- and middle-income countries. We examine the extent to which this change can be attributed to changes in fertility preferences versus fuller implementation of fertility preferences, a distinction at the heart of intense debates about the returns to investments in family planning services. We analyze national survey data from five major survey programs: World Fertility Surveys, Demographic Health Surveys, Reproductive Health Surveys, Pan-Arab Project for Child Development or Family Health, and Multiple Indicator Cluster Surveys. We perform regression decomposition of change between successive surveys in 59 countries (330 decompositions in total). Change in preferences accounts for little of the change: less than 10 percent in a basic decomposition and about 15 percent under a more elaborate specification. This is a powerful empirical refutation of the view that contraceptive change has been driven principally by reductions in demand for children. We show that this outcome is not surprising given that the distribution of women according to fertility preferences is surprisingly stable over time.

Effectiveness of erectogenic condom against semen exposure among women in Vietnam: Randomized controlled trial.

A key barrier to the consistent use of condoms is their negative effect on sexual pleasure. Although sexual pleasure is a primary motivation for engaging in sex and is an integral part of overall sexual health, most programs to improve sexual health operate within a pregnancy and disease-prevention paradigm. A new condom, CSD500 (Futura Medical Developments; Surrey, UK), containing an erectogenic drug was developed for use among healthy couples to improve sexual pleasure by increasing penile firmness, size and erection duration. We conducted a randomized controlled trial to test whether promoting the novel condom CSD500 for improved sexual pleasure is effective in reducing condomless sex compared to the provision of standard condoms with counseling for pregnancy and disease prevention. We randomized 500 adult, heterosexual, monogamous couples in Thanh Hoa province, Vietnam to receive either CSD500 (n = 248) or standard condoms (n = 252). At enrollment and after 2, 4, and 6 months, we interviewed women and sampled vaginal fluid to test for the presence of prostate-specific antigen (PSA), an objective, biological marker of recent semen exposure. We registered the protocol before trial initiation at ClinicalTrials.gov (identifier: NCT02934620). Overall, 11.0% of women were PSA positive at enrollment. The proportion of follow-up visits with PSA-positivity did not differ between the intervention (6.8%) and control arms (6.7%; relative risk, 1.01; 95% confidence interval, 0.66-1.54). Thus, we found no evidence that promoting an erectogenic condom to women in a monogamous, heterosexual relationship in Vietnam reduced their exposure to their partner's semen. These findings might not hold for other populations, especially those with a higher frequency of condomless sex.

Multiple Perspectives on Recent Trends in Unwanted Fertility in Low- and Middle-Income Countries.

The last four decades have witnessed large declines in fertility globally. This study uses data from 78 low- and middle-income countries to examine concurrent trends in unwanted fertility. Three measures of unwanted fertility are contrasted: the conventional unwanted total fertility rate, a proposed conditional unwanted fertility rate, and the percentage of births unwanted. Incidence of unwanted births and prevalence of exposure to unwanted births are both derived from answers to questions on prospective fertility preference, recognized as the most valid and reliable survey measure of preferences. Country-level trends are modeled both historically and with the decline in total fertility, with a focus on regional differentials. Results show that unwanted fertility rates-especially the conditional unwanted fertility rate-have declined substantially in recent decades. By contrast, the percentage of births unwanted has declined less, remaining stable or even increasing: from a birth cohort perspective, declines in unwanted fertility have been far more modest than the increased parental success in avoiding unwanted births. The regional patterns suggest that sub-Saharan Africa has several similarities with other major regions but also some peculiar features, including a recent stall in the decline of unwanted fertility that persists after controlling for the stage of fertility transition.

Passage of abortion ban and women's accurate understanding of abortion legality.

BACKGROUND: Legislative and judicial procedures related to banning abortion after 6 weeks of gestation in Ohio occurred from November 2018 to July 2019. These activities could have increased the belief that abortion has become illegal even though the 6-week abortion ban has never been in effect to date. OBJECTIVE: We sought to determine the prevalence and correlates of holding the belief that abortion is illegal in Ohio and to evaluate whether this belief increased over the time in which the 6-week abortion ban was introduced, passed twice, and then blocked in Ohio. STUDY DESIGN: We analyzed data from the first wave of the Ohio Survey of Women, a population-based survey of adult, reproductive-aged Ohioan women conducted from October 2018 to June 2019. During each of the 8 survey months, a median of 240 women (range, 70-761) completed the survey, including the survey question "Based on what you know or have heard, is it legal to get an abortion in your state?" We used multivariable logistic regression to assess the prevalence and correlates of believing that abortion is illegal in the state of Ohio. In addition, we used multinomial logistic regression to evaluate whether this belief increased over the interval during which women completed the survey, which roughly corresponded to the interval marked by legislative and judicial activities surrounding the 6-week abortion ban. RESULTS: Most of the 2359 participants understood that abortion is legal in the state of Ohio (64.0%) with the remainder believing it to be illegal (9.8%) or being unsure (26.2%). Correlates of believing abortion to be illegal included younger age, lower socioeconomic status, never married or married status, and Black, non-Hispanic race and ethnicity. Being unsure about legality did not change over time; however, the proportion of women who believed that abortion is illegal increased from the first month (4.5%) to the last month (15.9%) of the study period. Each additional study month was associated with a 17% increase in the odds of believing abortion to be illegal, in both unadjusted and adjusted models (odds ratio, 1.17; 95% confidence interval, 1.08-1.27). CONCLUSION: Attempts to restrict abortion access could contribute to women mistakenly believing that abortion is illegal despite it being unsuccessful.

Use of nonpreferred contraceptive methods among women in Ohio.

OBJECTIVES: We describe the prevalence and correlates of nonuse of preferred contraceptive method among women 18-44 years of age in Ohio using contraception. STUDY DESIGN: The population-representative Ohio Survey of Women had 2529 participants in 2018-2019, with a response rate of 33.5%. We examined prevalence of preferred method nonuse, reasons for nonuse, and satisfaction with current method among current contraception users (n = 1390). We evaluated associations between demographic and healthcare factors and preferred method nonuse. RESULTS: About 25% of women reported not using their preferred contraceptive method. The most common barrier to obtaining preferred method was affordability (13%). Those not using their preferred method identified long-acting methods (49%), oral contraception (33%), or condoms (21%) as their preferred methods. The proportion using their preferred method was highest among intrauterine device (IUD) users (86%) and lowest among emergency contraception users (64%). About 16% of women using permanent contraception reported it was not their preferred method. Having the lowest socioeconomic status (versus highest) (prevalence ratio [PR]: 1.47, 95% CI: 1.11-1.96), Hispanic ethnicity (versus non-Hispanic white) (PR: 1.83, 95% CI: 1.15-2.90), reporting poor provider satisfaction related to contraceptive care (PR: 2.33, 95% CI: 1.02-5.29), and not having a yearly women's checkup (PR: 1.31, 95% CI: 1.01-1.68) were significantly associated with nonuse of preferred method. Compared to preferred-method nonusers, higher proportions of preferred-method users reported consistent contraceptive use (89% vs. 73%, p < 0.001) and intent to continue use (79% vs. 58%, p < 0.001). CONCLUSIONS: Affordability and poor provider satisfaction related to contraceptive care were associated with nonuse of preferred contraceptive method. Those using their preferred method reported more consistent use. IMPLICATIONS: Cost is an important barrier for women in obtaining their preferred contraceptive methods. Low quality birth control care may also be a barrier to preferred-method use. Removal of cost barriers and improvement in contraceptive counseling strategies may increase access to preferred contraceptive methods.

Fertility preferences and subsequent childbearing in Africa and Asia: A synthesis of evidence from longitudinal studies in 28 populations.

Survey data on fertility preferences have played a central but controversial role in fertility research and advocacy for family planning. We summarize evidence from longitudinal studies in 28 Asian and African populations on the relationship between preferences and subsequent childbearing. While we found no consistent association between women's desire to delay childbearing and subsequent fertility, the baseline desire of women to stop childbearing was a powerful predictor of subsequent fertility in all populations and increased in strength as overall contraceptive use in the study populations rose. Partners' desire also exercised some influence but was of modest importance in most populations. However, the correspondence between desire to stop and behaviour was found to be far from perfect. Weak implementation of preferences by contraception is likely to be the major cause of this preference-behaviour discrepancy. Uncertainty and instability in preferences may also contribute to the discrepancy, particularly in sub-Saharan Africa.

Factors influencing satisfaction with oral contraceptive pills and injectables among past users in Kenya.

This study examines factors associated with satisfaction with oral pills and injectables among past users in Kenya based on a baseline survey for the 2-year prospective longitudinal study Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning conducted in 2016. Married women aged 15-39 years were interviewed using a structured questionnaire that captured information on reproduction, contraceptive knowledge and beliefs and attitudes towards contraception in general and towards specific methods. A multivariate logistic regression analysis was used to examine factors that influenced satisfaction with oral pills and injectables among past users in one urban site (Nairobi slums) and one predominantly rural site (Homa Bay in western Kenya). Results showed that dissatisfaction with pills and injectables is common among past users in both rural and urban Kenya (ranging from 39% to 56%). The distinctive contribution of the study lies in its ability to relate method-specific beliefs to overall satisfaction. Perception of effectiveness, ease of use and safety for long-term use had statistically significant influences on satisfaction with pills in both urban and rural sites while partner's approval was only important in Nairobi. For injectables, the perception of safety for long-term use was significant in the urban but not the rural site. Unlike pills, the belief that members of a woman's social network had used a method and found it satisfactory was a particularly powerful influence on satisfaction (AOR=2.8 in rural and 3.2 in urban). Perception of accessibility and fears about infertility were not found to be statistically associated with satisfaction for either pills or injectables. Surprisingly, the effects of all perceived contraceptive attributes were the same for major socio-demographic strata of the populations. The findings underscore the need for targeted counselling and community-based communication interventions to address negative and erroneous perceptions about family planning methods.

Method-Specific Attributes that Influence Choice of Future Contraception Among Married Women in Nairobi's Informal Settlements.

Despite an extensive evidence base on contraceptive method choice, it remains uncertain which factors are most influential in predisposing women toward certain methods and against others. This paper addresses this gap in knowledge by making use of rarely-measured perceptions about specific methods, perceived social network experience of methods, and women's own past experiences using specific methods. We draw on baseline data from the project, "Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning." Using conditional logit analysis, we ascertain which perceived method-specific attributes, including past experience of methods by women themselves and by their friends, predict preferred future contraceptive method among 317 women living in Nairobi slums who are using no method but intend to start in the next 12 months. Results show that satisfaction with past use, positive experience of use by a woman's social network, husband/partner's approval, lack of interference with menses, and perception of safety for long term use were all associated with choice of a future method.

Women's attitudes and beliefs towards specific contraceptive methods in Bangladesh and Kenya.

BACKGROUND: Missing from the huge literature on women's attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants). METHODS: In each site, 2424 to 2812 married women aged 15-39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study. RESULTS: While current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower. CONCLUSIONS: High levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.

Contraceptive Method Attributes and Married Women's Intention to Use the Pill or the Injectable in Rural Bangladesh.

CONTEXT: The factors underlying contraceptive method choice are poorly understood in many countries, including Bangladesh. It is important to understand how Bangladeshi women's perceptions of a method's attributes are associated with their intention to use that method. METHODS: Data on 2,605 married women aged 15-39 living in rural Matlab were taken from a baseline survey conducted in 2016. Conditional logit analysis was used to examine associations between 12 method attributes and intention to use the pill or the injectable among the 583 fecund women not currently using a method. Method attributes included those relating to ease of obtainment and use, efficacy, health effects, husband's approval, the experiences of the respondent and the experiences of women in the respondent's social network. RESULTS: Women tended to perceive the pill more positively than the injectable. For example, greater proportions of women reported believing that the pill is easy to use (90% vs. 72%) and does not cause serious health problems (75% vs. 38%). The likelihood that a woman intended to use a method was positively associated with her perception that it is easy to use (odds ratio, 2.9) and does not cause serious health problems (1.7) or affect long-term fertility (2.9). Satisfied past users of a method were more likely than never users to report intending to use the method (5.2). Intention to use the pill rather than the injectable was positively associated with education (2.0-3.6) and having a migrant husband (1.7). CONCLUSIONS: Negative beliefs not supported by evidence, particularly about the injectable, are associated with women's intention to use a contraceptive method. The results may be useful in improving contraceptive care, counseling and training.

RESUMEN Contexto: En muchos países, incluido Bangladesh, los factores en los que se basa la selección del método anticonceptivo son poco comprendidos. Es importante entender la forma en que las percepciones de las mujeres bangladesíes con respecto a los atributos de un método determinado se asocian con su intención de usar ese método. Métodos: A partir de una encuesta de línea de base llevada a cabo en 2016, se tomaron datos de 2,605 mujeres casadas, de 15 a 39 años, que vivían en Matlab rural. Se utilizó análisis Logit condicional para examinar las asociaciones entre 12 atributos del método y la intención de 583 mujeres fecundas, que no estaban usando un método, de usar la píldora o el inyectable. Los atributos del método incluían los relacionados con la facilidad de obtención y uso, la eficacia, los efectos sobre la salud, la aprobación del esposo, las experiencias de las encuestadas y las experiencias de las mujeres expresadas en las redes sociales de las encuestadas. Resultados: Las mujeres mostraron una tendencia a percibir la píldora de manera más positiva que el inyectable. Por ejemplo, una mayor proporción de mujeres reportó que consideraba la píldora como un método fácil de usar (90% vs. 72%) y que no causa problemas de salud graves (75% vs. 38%). La probabilidad de que una mujer intentara usar un método se asoció positivamente con su percepción de que es fácil de usar (razón de probabilidades, 2.9), que no causa problemas de salud graves (1.7) o que no afecta la fecundidad a largo plazo (2.9). Las usuarias satisfechas que ya habían usado un método fueron más propensas que las que nunca habían sido usuarias a informar que intentaban usar el método (5.2). La intención de usar la píldora en lugar del inyectable se asoció positivamente con el grado de escolaridad (2.0­3.6) y con el hecho de tener un esposo migrante (1.7). Conclusiones: Las creencias negativas no respaldadas por evidencia, particularmente sobre el inyectable, están asociadas con la intención de las mujeres de usar un método anticonceptivo. Los resultados pueden ser útiles para mejorar la calidad de la atención anticonceptiva, la consejería y la capacitación.

RÉSUMÉ Contexte: Les facteurs à la base du choix de méthode contraceptive sont mal compris dans de nombreux pays, notamment au Bangladesh. Il importe de cerner en quoi l'idée que se font les Bangladaises des propriétés d'une méthode sont associées à leur intention de pratiquer cette méthode. Méthodes: Les données relatives à 2 605 femmes mariées âgées de 15 à 39 ans et vivant dans les milieux ruraux de Matlab ont été obtenues d'une enquête de référence menée en 2016. Les associations entre 12 propriétés de méthode et l'intention d'utiliser la pilule ou le contraceptif injectable parmi les 583 femmes fécondes qui ne pratiquaient alors aucune méthode ont été examinées par analyse logit conditionnelle. Les propriétés des méthodes considérées étaient la facilité d'obtention et d'emploi, l'efficacité, les effets sur la santé, l'approbation du mari, l'expérience de la répondante et celle des femmes membres du réseau social de la répondante. Résultats: Les femmes tendaient à percevoir la pilule de manière plus positive que l'injectable. Par exemple, de plus grandes proportions de femmes ont déclaré croire que la pilule est facile à utiliser (90% par rapport à 72%) et qu'elle ne cause pas de problèmes de santé graves (75% par rapport à 38%). La probabilité qu'une femme ait l'intention d'utiliser une méthode s'est avérée associée positivement à sa perception de la facilité de son emploi (RC, 2,9) et d'absence d'effets secondaires graves pour la santé (1,7) ou d'effet sur sa fécondité à long terme (2,9). Les anciennes utilisatrices satisfaites d'une méthode se sont révélées plus susceptibles que les femmes qui ne l'avaient jamais pratiquée de déclarer avoir l'intention de l'utiliser (5,2). L'intention d'utiliser la pilule plutôt que l'injectable présente une association positive avec le niveau d'éducation (2,0­3,6) et avec le fait d'avoir un mari migrant (1,7). Conclusions: Des croyances négatives non avérées, concernant en particulier le contraceptif injectable, sont associées à l'intention des femmes de pratiquer une méthode contraceptive. Les résultats peuvent être utiles à l'amélioration de la qualité des soins, du conseil et de la formation en matière de contraception.

Reasons for unmet need for family planning, with attention to the measurement of fertility preferences: protocol for a multi-site cohort study.

BACKGROUND: Unmet need for family planning points to the gap between women's reproductive desire to avoid pregnancy and contraceptive behaviour. An estimated 222 million women in low- and middle-income countries have unmet need for modern contraception. Despite its prevalence, there has been little rigorous research during the past fifteen years on reasons for this widespread failure to implement childbearing desires in contraceptive practice. There is demographic survey data on women's self-reported reasons for non-use, but these data provide limited insight on the full set of possible obstacles to use, and one may doubt the meaningfulness of explanations provided by non-users alone. To rectify this evidence gap, this study will gather extensive information on women's perceptions of contraception (generic and method-specific) and their past contraceptive experience, and it will allow for more complexity in fertility preferences than is standard in demographic surveys. METHODS: A multi-site cohort study will be conducted in urban Kenya, rural Kenya, and rural Bangladesh. In each setting trained fieldworkers will recruit and interview 2600 women, with participants re-interviewed at 12 and 18 months. Data will be collected using a questionnaire whose development was informed by a review of existing literature and instruments from past studies in both developed and developing countries. Dozens of experts in the field were consulted as the instrument was developed. The questionnaire has three main components: a sub-set of Demographic and Health Survey items measuring socio-demographic characteristics, reproductive history, and sexual activity; additional questions on prospective and retrospective fertility preferences designed to capture ambivalence and uncertainty; and two large blocks of items on (i) generic concerns about contraception and (ii) method-specific attributes. The method-specific items encompass eight modern and traditional methods. DISCUSSION: Policy and programmes intended to reduce unmet need for contraception in developing countries should be informed by clear understanding of the causes of this phenomenon to better reflect the population needs and to more effectively target planning and investments. To this end, this study will field an innovative instrument in Kenya and Bangladesh. The information to be collected will support a rigorous assessment of reasons for unmet need for family planning.

Understanding unmet need: history, theory, and measurement.

During the past two decades, estimates of unmet need have become an influential measure for assessing population policies and programs. This article recounts the evolution of the concept of unmet need, describes how demographic survey data have been used to generate estimates of its prevalence, and tests the sensitivity of these estimates to various assumptions in the unmet need algorithm. The algorithm uses a complex set of assumptions to identify women: who are sexually active, who are infecund, whose most recent pregnancy was unwanted, who wish to postpone their next birth, and who are postpartum amenorrheic. The sensitivity tests suggest that defensible alternative criteria for identifying four out of five of these subgroups of women would increase the estimated prevalence of unmet need. The exception is identification of married women who are sexually active; more accurate measurement of this subgroup would reduce the estimated prevalence of unmet need in most settings.

Unmet need and fertility decline: a comparative perspective on prospects in sub-Saharan Africa.

This study assesses how changes in unmet need for family planning have contributed to contemporary fertility declines, and the implications of this historical record for further fertility decline, especially in sub-Saharan Africa. We examine joint trends at the national level in fertility, unintended fertility, and unmet need. We bring unintended fertility into the analysis because the underlying rationale for reducing unmet need is to avert unintended pregnancies and births. The association over time between unmet need and fertility is investigated using survey data from 45 countries in Africa, Asia, and Latin America and the Caribbean from the mid-1970s to the present. The empirical analysis finds that reduction in unmet need, especially unmet need for limiting, is strongly associated with fertility decline in Latin America and the Caribbean and in Asia and North Africa. Fertility decline in sub-Saharan Africa is weakly associated with trends in unmet need (and satisfaction of demand). We propose that the stark regional difference is due to measurement problems and to the fundamentally different character of fertility decline in sub-Saharan Africa, itself reflective of basic differences in pretransition reproductive regimes.

Migration and Marriage: Modeling the Joint Process.

BACKGROUND: Previous research on inter-relations between migration and marriage has relied on overly simplistic assumptions about the structure of dependency between the two events. However, there is good reason to posit that each of the two transitions has an impact on the likelihood of the other, and that unobserved common factors may affect both migration and marriage, leading to a distorted impression of the causal impact of one on the other. OBJECTIVE: We will investigate relationships between migration and marriage in the United States using data from the National Longitudinal Survey of Youth 1979. We allow for inter-dependency between the two events and examine whether unobserved common factors affect the estimates of both migration and marriage. METHODS: We estimate a multi-process model in which migration and marriage are considered simultaneously in regression analysis and there is allowance for correlation between disturbances; the latter feature accounts for possible endogeneity between shared unobserved determinants. The model also includes random effects for persons, exploiting the fact that many people experience both events multiple times throughout their lives. RESULTS: Unobserved factors appear to significantly influence both migration and marriage, resulting in upward bias in estimates of the effects of each on the other when these shared common factors are not accounted for. Estimates from the multi-process model indicate that marriage significantly increases the hazard of migration while migration does not affect the hazard of marriage. CONCLUSIONS: Omitting inter-dependency between life course events can lead to a mistaken impression of the direct effects of certain features of each event on the other.