[Knowledge and practice of contraception in Haiti: a factor in fertility decline over the last two decades?]. / La connaissance et la pratique de la contraception en Haiti: facteur de la baisse de la fecondite depuis deux decennies?

PIP: Information on contraceptive knowledge and practice in Haiti is available from four national surveys taken over 20 years: the 1977 Haiti Fertility Survey, the 1983 Contraceptive Prevalence Survey, the 1989 National Survey of Contraception, and the 1994-95 Survey of Mortality, Morbidity, and Use of Services. The proportion of Haitian women in union declaring knowledge of at least one contraceptive method increased from 83% in 1977 to 99% in 1994-95. The influence of educational level and rural or urban residence on knowledge declined over time and was virtually nil by 1995. The surveys indicated that, among women in union, 18% used a contraceptive method in 1977, 7% in 1983, 10% in 1989, and 17% in 1995. Educated and urban women had higher rates of contraceptive usage. The use of traditional methods has declined since 1977, while the proportion of women using modern methods increased from 5% in 1977 to 13% in 1995. Combining the survey results reporting contraceptive practice with analyses of the proximate determinants indicates that contraceptive usage only partially explains the decline in Haiti's total fertility rate from 6 in 1982-83 to 4.8 in 1995. Assuming that the natural fertility rate has remained constant at 17.7 children/woman over the past 2 decades, it was estimated, using the Bongaarts method, that in 1994-95 7.4 births were avoided due to marriage patterns, 3.6 due to breast-feeding and postpartum infecundity, 1.3 due to contraception, and 0.6 due to abortion. It is very likely that the impact of duration of union will decline in the future, as premarital sexual activity increasingly becomes the norm.^ieng

The clandestine epidemic: the practice of unsafe abortion in Latin America.

In Latin America, induced abortion is the fourth most commonly used method of fertility regulation. Estimates of the number of induced abortions performed each year in Latin America range from 2.7 to 7.4 million, or from 10 to 27 percent of all abortions performed in the developing world. Because of restrictive laws, nearly all of these abortions, except for those performed in Barbados, Belize, and Cuba, are clandestine and unsafe, and their sequelae are the principal cause of death among women of reproductive age. One of every three to five unsafe abortions leads to hospitalization, resulting in inordinate consumption of scarce and costly health-system resources. Increased contraceptive prevalence and restrictive abortion laws have not decreased clandestine practices. This article addresses how the epidemic of unsafe abortion might be challenged. Recommendations include providing safer outpatient treatment and strengthening family planning programs to improve women's contraceptive use and their access to information and to safe pregnancy termination procedures. In addition, existing laws and policies governing legal abortion can be applied to their fullest extent, indications for legal abortion can be more broadly interpreted, and legal constraints on abortion practices can be officially relaxed.

The search for meaning: RU 486 and the law of abortion.

The advent of RU 486 (mifepristone), a steroid analogue capable of inducing menses within 8 to 10 weeks of a missed menstrual period, has provoked a firestorm of concern and controversy. When used in conjunction with prostaglandin (RU 486/PG), it is at least 95% effective. Used in France principally to terminate confirmed pregnancies very early in the process of gestation, RU 486 raises many interesting legal questions. This article focuses on whether and how RU 486/PG can be accommodated within the framework of the world's current abortion laws. Four avenues are explored and conclusions drawn. First, it is clear that RU 486/PG can be used readily, if approved, within the regimens established by liberal abortion laws, as has been the experience in France, the United Kingdom, and even China. Second, although unlikely, the introduction of this new technology may inspire a reexamination of restrictive abortion statutes themselves. Third, some of the presently restrictive laws may be interpreted to permit RU 486/PG use as a legal procedure, for a very narrow range of reasons. Finally, in some settings the early use of RU 486/PG (before pregnancy can be confirmed) may fall outside the reach of abortion legislation and hence be acceptable from a legal point of view.

Adolescent sexuality and fertility in Kenya: a survey of knowledge, perceptions, and practices.

This article presents findings from a survey conducted in Kenya in 1985 of the reproductive health knowledge, attitudes, and practices among more than 3,000 unmarried Kenyan youth, students and nonstudents, between the ages of 12 and 19. The survey was designed to elicit information that would be useful in gauging the kinds of problems Kenyan adolescents face in order to design programs that meet their needs. The study shows that although a solid majority of adolescents appear to have received information on reproductive health, the quality of the information is generally low. Fewer than 8 percent could correctly identify the fertile period in a woman's menstrual cycle. A substantial proportion of the population surveyed, more than 50 percent, is sexually active, having initiated intercourse some time between 13 and 14 years of age, on average. In spite of a general disapproval of premarital sex (but approval of the use of contraceptives among the sexually active), most of the sexually active population--89 percent--have never used contraceptives. The many contradictions between attitudes and practices pose serious questions and demonstrate the need to reexamine the programs (and policies) that provide access to reproductive health services to adolescents in Kenya.

PIP: Not withstanding the concern for the health consequences of early sexual activity, early untimely pregnancy results in expulsion from school at the rate of 10% annually in Kenya and economic advancement practice, and reproductive health of 1513 females and 1803 males aged 12-19 was conducted in 1985 in 7 rural and 2 urban districts and represents the 8 major ethnic groups in Kenya. The simple random sample was analyzed with the statistical software package (SPSS). 12 subgroups were developed in spite of the small numbers by gender, age, and student status for students (81%: 78% females and 84% male), and educational level for nonstudents. This grouping and the use of the Family Health International/Pathfinder adolescent fertility questionnaire make it comparable to studies in other countries. The majority were raised in rural areas. The findings show that attitudes are changing toward age at marriage of 22 for women and 25.5 for men (women's responses); men's recommendations were lowers, and the lower educated nonstudents reported a lower age versus higher educated nonstudents. Age at birth of first child paralleled age at 1st marriage. Desired number of children was 4-5. In contract to the attitudes expressed, prior surveys of women 15-19 years old showed 75% married in these years. Current fertility is 8.1 children with most 1st births before age 20. This study also revealed a lack of knowledge of reproductive health, with less than 1 in 10 recognizing the fertility cycle, and only 50% knowing the pregnancy could occur at 1st intercourse. Knowledge appears to increase with level of education. Knowledge of at least 1 modern contraceptive was 75% and the majority approved of use, but actual ever use among the sexually active was 11%. The reasons given for nonuse were lack of information and difficulty in contraceptive access. 60-65% disapproved of premarital sexual relations, yet 51% reported sexual activity. The mean age of 1st experience was 13. Currently distribution of contraceptives among adolescents is disapproved of at the policy level. Abortion was not approved of, and it appears abortion is used in order to remain in school. A variety of educational approaches is suggested and 6 challenging questions are posed for those who implement policy. As the shadow of AIDs lengthens perhaps the issue of adolescent contraception will received proper attention.

Facts of life for adults.

PIP: The editorial commentary reflects the desire for openness in providing contraceptive services for adolescents, rather than pretending that the emperor has new clothes. The simile is used to expose the coverup intended by adults who desire adolescent sexual behavior that does not exist. Examples of 4 European countries, (Sweden, Netherlands, France, and England and Wales) who support contraceptive use for teenagers are given. Lessons can be learned from these countries which have a 3 times lower teenage pregnancy rate than the US. In the Netherlands contraceptives are used by 90% of sexually active teenagers. The birth rate of 14/1000 and the abortion rate of 10/1000 is the lowest of the 4 countries. Swedish contraceptive, birth, and abortion rates are similar, but the age of the 1st sexual experience is the earliest. England and Wales has a similar contraception rate but the birth rate is also 45/1000 and the abortion rate is slightly higher. All countries provide teenage contraceptive services free or at low cost as well as sex education. The debate over contraception in other countries links access to sexual activity, when the facts of life are that teenagers become sexually active before contraception. In Sweden to curb abortions, contraception was increased between 1974-1981 with a concomitant decline of 27% in the abortion rate. In the US, it rose 59%. The experience of all 4 countries has been to reduce abortion, but still provide access to abortion services. The formula for successful management of teenage sexuality such as sex education, low cost contraceptive services, and access to early safe abortion services may not meet the needs of the AIDS pandemic. Many questions arise and Europe may provide the answers.^ieng

[Adolescent sexuality in Peru]. / La sexualidad en la adolescencia en el Peru

PIP: 22% of the population of Peru, or 4.25 million individuals, is between the ages of 11 and 19 years. A survey was performed on a sample of 6,000 adolescents living in Lima, Cajamarca, Huarez, and Supe. Surveys were performed in a variety of locations, including school classrooms, maternity wards, schools, and work places. The questionnaire was constructed based on a format that had been tested in Nigeria; questions dealt with socioeconomic background, sex behavior, contraceptive behavior, pregnancy history, and health practices and knowledge. 60% of the adolescents were women and 40% were men. 41% had had at least 1 sexual experience; among 18-year-olds, this % rose to 55. Only 10% were in stable union. Married adolescents tended to have begun sexual relations sooner in life. Early sexual relations were more common among men than among women, and more common among non-religious adolescents than among Catholics. Fewer than 12% of the adolescents had at 1 time used contraceptives. Contraceptive use was more prevalent among adolescents from wealthier socioeconomic groups, and more prevalent in Lima than in other regions surveyed. Of adolescents using contraceptives, 38% used condoms, 24% used oral contraceptives, and 15% used rhythm methods. Most adolescents who did not use contraceptives failed to do so because of lack of knowledge. Almost 1/4 of the young women had had a pregnancy. 18.5 of these had abortions, usually in a hospital. The importance of supporting educational prevention programs is underlined.^ieng

The crucial role of the private sector.

PIP: Private support for the development of family planning programs continues to grow and now includes industries that provide family planning services, commercial outlets that distribute contraceptives, community groups that help to build demand, private medical practitioners who include contraception as a part of health care, organizations that provide technical and financial assistance to developing country programs, pharmaceutical firms, and foundations that underwrite contraceptive research. Although the mix of private and public programs differs from country to country, these 2 family planning programs complement each other and often work in close partnership. The private sector has the advantages of being able to pioneer innovative programs the public sector is unwilling or unable to pursue, to bring foreign financial and technical assistance to developing countries without political implications, and to achieve financially self-sustaining family planning efforts that are linked to other development efforts. In many countries, the private sector has been instrumental in developing a national family planning program and in eliminating barriers to family planning in countries with restrictive laws and policies. The private sector has been especially important in pioneering grassroots programs that improve the status of women through education, health care, training, and economic opportunity.^ieng

Sexual behavior, contraceptive practice, and reproductive health among Nigerian adolescents.

In the context of a high and increasing incidence of unwanted pregnancy among Nigerian adolescents, a sample survey of never-married residents of the Ibadan area, aged 14 to 25 years, was conducted in 1982 to learn about their perceptions and practices relating to reproductive health. A substantial proportion of the young unmarried population is sexually active, and despite comparatively high contraceptive prevalence among that proportion, many are still engaging in sexual relations without benefit of contraceptive protection. Nearly half of the female students interviewed at both the secondary and university levels have been pregnant, as have two-thirds of those not currently enrolled in school. Among those respondents who had been pregnant, almost all reported that they voluntarily terminated their pregnancies. Existing and needed contraceptive services for the adolescent population are discussed.

Sex education laws and policies.

Sex education laws and policies are important in facilitating or blocking efforts to provide adolescents with sexuality education and information. Legislation in developing and industrialized countries concerns both sexuality education in schools and adolescents' access to information on contraception and abortion. Although laws and policies vary, the trend is to remove laws restricting sex education and information and to promote the flow of reproductive health information for adolescents. The integration of sex education with programs that provide contraceptive services offers the promise of preventing unwanted pregnancy in adolescents, with its all too frequent tragic health and social consequences.

PIP: Sex education laws and policies are important in facilitating or blocking efforts to provide adolesents with sexuality education and information. It is important that the process of education go forward for health reasons, if for no other. Legislation in developing and industrialized countries concerns both sexuality education in schools and adolescents' access to information on contraception and abortion. A factual presentation about sexual matters, including contraception and other important health-related subjects, is simply an honest attempt to provide young people with essential information and to instill knowledge and create understanding about their own health needs. Reproductive health education is a necessary step toward resolving the health, social, economic and demographic problems that surround the phenomena of early sexuality, pregnancy and childbearing. One of the real difficulties to be faced in the context of sex education is persuading authorities to change the policies that regulate curriculum content. The appropriateness of course content is always determined by local mores and cultural views. Even as laws and policies vary, the trend is to remove laws restricting sex education and information and to promote the flow of reproductive health information for adolescents. Many of the laws and policies encourage and sometimes require, the involvement of parents. This can only enhance the reasonableness of the design of materials. Prevention of early and unwanted pregnancy in adolescents, with its all too frequent tragic consequences, would make an enormous contribution to health, not to mention social conditions, in developing and industrialized countries alike. A cornerstone of effective reproductive health education is legislation to assure the free flow of information on contraception, human relationships, and sexuality. Laws and policies can do much to promote successful sexuality education programs in schools. They can encourage the spread of information throgh counseling centers, the press, and in commercial advertising and display of contraceptives. All of this, despite loud voices to the contrary, can help to provide responsible solutions to the pressing problems associated with adolescent sexuality and fertility.

Adolescent fertility: worldwide concerns.

PIP: There is growing concern over the adverse health, social, economic, and demographic effects of adolescent fertility. Morbidity and mortality rates ar significantly higher for teenage mothers and their infants, and early initiation of childbearing generally means truncated education, lower future family income, and larger completed family size. Adolescent fertility rates, which largely reflect marriage patterns, range from 4/1000 in Mauritania; in sub-Saharan Africa, virtually all rates are over 100. In most countries, adolescent fertility rates are declining due to rising age at marriage, increased educational and economic opportunities for young women, changes in social customs, increased use of contraception, and access to abortion. However, even if fertility rates were to decline dramatically among adolescent women in developing countries, their sheer numbers imply that their fertility will have a major impact on world population growth in the years ahead. The number of women in the world ages 15-19 years is expected to increase from 245 million in 1985 to over 320 million in the years 2020; 82% of these women live in developing countries. As a result of more and earlier premarital sexual activity, fostered by the lengthening gap between puberty and marriage, diminished parental and social controls, and increasing peer and media pressure to be sexually active, abortion and out-of-wedlock childbearing are increasing among teenagers in many developed and rapidly urbanizing developing countries. Laws and policies regarding sex education in the schools and access to family planning services by adolescents can either inhibit or support efforts to reduce adolescent fertility. Since contraceptive use is often sporadic and ineffective among adolescents, family planning services are crucial. Such programs should aim to reduce adolescents' dependence on abortion through preventive measures and increase awareness of the benefits of delayed sexual activity. Similarly, sex education should seek to provide a basis for intelligent, informed decision making. Programs tailored to reach teenagers in schools, recreational centers, and the workplace have particular potential.^ieng

Depo-Provera--ethical issues in its testing and distribution.

Ethical issues relating to the use of the injectable contraceptive in developed and developing countries alike involve public policy decisions concerning both criteria for testing a new drug and individual choices about using a specific form of contraception approved for national distribution. Drug testing consists of an important but still evolving set of procedures. Depo-Provera is not qualitatively different from any other drug and some unpredictable risks are inevitable, even after extensive animal experiments and clinical trials. In assessing the risks and benefits of Depo-Provera use, epidemiological data from large-scale human use is now beginning to become more important than data from animal experiments and clinical trials. The consumer's best interest is central to any ethically responsible system of drug distribution. Systems of informed choice are needed, even in societies where illiteracy remains common and medical services are weak. In the case of a contraceptive, the risks of non-use leading to unintended pregnancy, which can result in high mortality, are relevant as well as the side-effects of the method. An attempt, therefore, is made here to categorise those issues which are universal and those which are country-specific.

PIP: Ethical issues relating to the use of the injectable contraceptive in developed and developing countries alike involve public policy decisions concerning both criteria for testing a new drug and individual choices about using a specific form of contraception approved for national distribution. Drug testing consists of an important but still evolving set of procedures. Depo-Provera is not qualitatively different from any other drug and some unpredictable risks are inevitable, even after extensive animal experiments and clinical trials. In assessing the risks and benefits of Depo-Provera use, epidemiological data from large scale human use is now beginning to become more important than data from animal experiments and clinical trials. The consumer's best interest is central to any ethically responsible system of drug distribution. Systems of informed choice are needed, even in societies where illiteracy remains common and medical services are weak. In the case of a contraceptive, risks of nonuse leading to unintended pregnancy, which can result in high mortality, are relevant as well as are the side effects of the method. An attempt, therefore, is made here to categorize those issues which are universal and those which are country specific.^ieng

Reproductive health, youth, and the law.

PIP: This article surveys legal and policy approaches to adolescent health care programs and presents data on the availability of sex education programs, contraception, and abortion for adolescents in selected countries in the developed and developing world. The age at which youth are considered legally able reach independent decisions on matters affecting their health varies from country to country, although there is a trend toward setting the "age of majority" at 18 years. There has also been a trend toward viewing laws that require parental consent to health care and treatment as a barrier to health rather than a form of protection. Alternative legal approaches to the dilemma of consent have included lowering the age of majority for purposes of medical treatment, permitting professionals tojude whether an adolescent has sufficient maturity to give consent, and the use of third-party consent (e.g. child advocate). Cultural diversity mitigates against a universal legal approach to reproductive health education. There is wide variation in the policy response to questions such as whether reproductive health education courses should be permitted within the school curriculum, whether they should be obligatory or elective, if there should be separate courses or integration of fertility-related material into existing courses, and whether the sexes should be separated for instruction. There is awareness that formal sex education programs in a school setting cannot reach the large number of adolescents outside the educational system, but laws regarding public dissemination of reproductive health information are often restrictive. Contraceptive-related law and policy affect who has access to contraception and under what conditions. Abortion law takes 2 different forms: those that establish the retionales on which a given pregnancy may be terminated and those that establish the formal procedural requirements that must be met. It is concluded that, overall, law and policy have not kept pace with the health care needs of adolescens. They have in many cases inhibited the provision of health care. The challenge is to get law and policy to address adolescent health care issues in a way that solves problems rather than creates them.^ieng

Health care for handicapped adolescents: international legislative and policy trends.

Between 1970-1976, 45 countries enacted or made adjustments to laws on health care for the handicapped. This article explores some of the legal arrangements made to address the issue of health care for the handicapped adolescent. It reviews the legal definition of "handicapped" and analyzes the legislative support created for health care programs. Most programs are comprehensive. They focus on prevention, detection and reporting, as well as treatment and rehabilitation. Better care for disabled adolescents is one of the more important intended results of recent legislation directed to the handicapped. Rehabilitation has been increasingly recognized as a right. Prevention is an increasing focus. Legislation, however important, is only a beginning; it expresses the political will be create programs to address the issue. The challenge is to implement the law.

Menstrual regulation and the law.

The advent of menstrual regulation techniques has further clouded the once-clear legal distinction between contraception and abortion. This study, which attempts to assess the relationship between menstrual regulation and abortion laws throughout the world, focuses on the three distinct types of abortion laws that impinge on menstrual regulation practice: (1) those that focus on the "intent" to interrupt pregnancy, (2) those that require proof of pregnancy and (3) those that make abortion readily accessible for a wide variety of indications.

Roles for non-physicians in fertility regulation: an international overview of legal obstacles and solutions.

For more than a decade the roles of non-physicians in fertility regulation have been expanding. The article discusses the relationship between law and the expansion of those roles. The laws and regulations which effect these roles fall into three basic categories: those controlling the medical and other health-related professions, those regulating drugs and devices, and those affecting specific fertility regulation services. These in turn may either inhibit or facilitate the expansion of roles for non-physicians. Where legal barriers arise, and no feasible legal solution is developed, expansion of roles is difficult, if not impossible, as the law invariably reflects the prevailing views on who should provide fertility regulation services. In many countries, however, as roles have been changing, the law has been changing too in a way which affords legal protection to non-physicians. The emphasis to date has been on permitting them to assume expanded roles in the provision of contraceptives. Non-physicians are authorized to prescribe the Pill in at least 10 countries and to re-supply the Pill after prescription in seven others. Non-physicians are permitted to insert IUDs in at least 10 countries. Pilot projects are presently testing the feasibility of permitting non-physicians to perform sterilizations and early abortions. The law has an impact, for good or ill, on all of these arrangements.

Roles for non-physicians in fertility regulation: legal obstacles and new approaches for change.

PIP: In dealing with legal dimensions of the creation of new roles for non-physicians, focus is on 2 separate but related questions: what are the obstacles to expanding the roles of non-physicians and what contribution can the law make to overcome them. Thus far the emphasis has been on using non-physicians to provide contraceptive services but in some countries they are being trained and used as part of pilot projects to perform sterilizations and early abortions. 1 initial obstacle to expanding the role of non-physicians is posed by medical practice statutes, currently in force in all countries. Legislation regulating the practice of nursing and midwifery empowers the non-physicians to carry out technical procedures in instruction but leave little room for decision making. Consequently, the nurse or midwife lacks the legal capacity to play an active independent role. Pharmaceutical laws place 2 major legal restrictions on the distribution of contraceptives, particularly orals: the doctor's prescription and the pharmacy sale requirements. In the last 10 years, several countries have revised their laws and regulations to allow non-physicians to participate more actively in the provision of fertility regulation services. A survey of 28 countries where non-physicians actively provide services reveals that 3 principal legal approaches have been used to bring about this change: delegation by a physician, interpretation of the law, and outright authorization.^ieng

Law, policy and the use of non-physicians in family planning service delivery.

PIP: A great deal of attention is being devoted to the use of nonphysicians to provide such fertility control services as contraception, sterilization, and abortion. Legal obstacles exist, however, which must be overcome before the role of nonphysicians can be expanded. Such obstacles include medical practice statutes, nursing and midwifery legislation, and laws and regulations directly related to such fertility control measures as the provision of contraceptions and the performance of sterilizations. On the other hand, the following 3 main approaches have been used to permit increased participation of nonphysicians: delegation of tasks by physicians, liberal interpretation of existing laws, and authorization. Thus, the important elements in expanding the roles of nonphysicians are 1) authorization; 2) training; 3) qualification; 4) supervision; and 5) opportunities for referrals to physicians. The ultimate role of paramedicals will depend upon the continued simplification of technology, the results of research on the quality of care which they can provide, the attitudes of the medical profession, and the elimination of the legal ambiguities and obstacles which exist.^ieng