Social inequalities in the use of contraceptives in adult women from Southern Brazil / Desigualdades sociais no uso de contraceptivos em mulheres adultas no Sul do Brasil

ABSTRACT OBJECTIVE: To describe the contraceptive methods used by adult women and the associated socioeconomic and demographic factors. METHODS: Population-based cross-sectional study with 20 to 49-year-old women from São Leopoldo, state of Rio Grande do Sul, in 2015. Three outcomes were considered to analyze the association with demographic and socioeconomic characteristics: use of oral contraceptive pills, tubal ligation and male condom. The crude prevalence ratios, stratified by age, and 95% confidence intervals (95%CI) were obtained using Poisson regression, taking the experimental error into account. RESULTS: A total of 736 women, aged from 20 to 49 years old, were evaluated. The prevalence of the use of oral contraceptive pills, tubal ligation and male condom were respectively 31.8% (95%CI 28.4-35.3), 11.1% (95%CI 9.0-13.6) and 10.9% (95%CI 8.7-13.3). In addition, 10.5% (n = 77) of the women reported making combined use of oral contraceptive pills and condom. In the stratified analysis, younger women with lower education level and from lower social classes reported less use of oral contraceptive pills. Tubal ligation was more prevalent among the lower social classes, but only in the age group from 30 to 39 years old. No differences were found in relation to male condom. CONCLUSIONS: The results indicated that differences persist in relation to contraception, which can be associated with both the difficulties of access to these inputs and the frailty of actions in reproductive health to achieve the needs and preferences of women who are more socially vulnerable.

RESUMO OBJETIVO: Descrever os métodos contraceptivos utilizados e fatores demográficos e socioeconômicos associados em mulheres adultas. MÉTODOS: Estudo transversal de base populacional com mulheres de 20 a 49 anos de São Leopoldo, RS, em 2015. Foram considerados três desfechos para analisar a associação com características demográficas e socioeconômicas: uso de anticoncepcional oral, ligadura tubária e uso de preservativo masculino. Foram obtidas razões de prevalências, brutas e estratificadas por idade, e intervalos de confiança de 95% (IC95%) por meio de regressão de Poisson, levando em conta o erro de delineamento. RESULTADOS: Foram avaliadas 736 mulheres com idades entre 20 e 49 anos. A prevalência de uso de anticoncepcional oral, de ligadura tubária e de uso de preservativo masculino foram, respectivamente, 31,8% (IC95% 28,4-35,3), 11,1% (IC95% 9,0-13,6) e 10,9% (IC95% 8,7-13,3). Além disso, 10,5% (n = 77) das mulheres relataram fazer uso combinado de anticoncepcional oral e preservativo masculino. Na análise estratificada, as mulheres mais jovens, de menor escolaridade e classe econômica mais baixa relataram menor uso de anticoncepcional oral. Já a ligadura tubária foi mais prevalente entre as de classe econômica mais baixa, mas apenas na faixa etária de 30 a 39 anos. Não foram encontradas diferenças quanto ao preservativo masculino. CONCLUSÕES: Os resultados indicaram que ainda persistem diferenças quanto à contracepção, o que pode se relacionar tanto a dificuldades no acesso a esses insumos como a fragilidades das ações em saúde reprodutiva para atingir as necessidades e preferências das mulheres em maior vulnerabilidade social.

Unmet need for family planning in Jamaica.

This study updates and extends estimates for unmet need and total demand for family planning for Jamaican women in the reproductive age group, 15-49. The findings suggest that, as yet unmet need for family planning was 22.7%, compared to 16% previously estimated.

PIP: This paper updated and extended the unmet need for family planning services assessment for Jamaican women made by McFarlane and Warren (1989), and related this need to differences in background and socioeconomic characteristics. The data came from the 1989 Jamaican Contraceptive Prevalence Survey collected between June 1988 and November 1989. These analyses were restricted to 4451 women of reproductive age (15-49) if they had a common law or visiting partner relationship. Of the total sample, only 17% of women were legally married and living with their husband, compared to 23% in common law unions and 28% in visiting unions. While most women were not using a method to space births (8.4%) there was also a considerable proportion of women (3.8%) who were not using a method of contraception to delay the first pregnancy. Nearly one-third of spacers were delayers. Younger women had the greatest unmet need for family planning services to delay the first birth. Women with primary and secondary levels of education demonstrated high unmet need for family planning. Unmet need was slightly higher among urban than rural women, and the unmet need to delay was greatest among urban women. Women in visiting unions demonstrated a greater unmet need compared to women who were married and those who were in common law relationships. In addition, the greatest unmet need for the entire sample by parity was among women with 1 child (29.3%). Delayers were younger (83.2% aged 15-24 vs. 45.6% for spacers), better educated (82.0% with more than primary education vs. 66.8% for spacers), and more likely to be urban dwellers (39.5% vs. 31.6% for spacers). A slightly greater proportion of delayers was living in common law and visiting unions than spacers (92.8% and 86.6%, respectively). In all, 22.7% of women aged 15-49 who were in union and who were pregnant or amenorrheic as a result of an unintentional pregnancy had an unmet need for family planning compared to 16% previously estimated.

Contraceptive use and sterilization among Puerto Rican women.

A comparison of contraceptive use in the early to mid-1980s among married Puerto Rican women aged 15-49 in the New York City area reveals that island-born Puerto Rican women living in New York rely on female sterilization to nearly the same extent as do women living in Puerto Rico (45% and 41%, respectively) and that mainland-born Puerto Rican women use sterilization as much as do all women in the United States (19% for both groups). Puerto Rican women in New York use reversible methods to a greater extent than do women in Puerto Rico (22% v. 16%), but to a lesser extent than do all women in the United States (37%). Although mainland-born Puerto Rican women in New York use reversible methods more than do island-born women in New York (42% v. 23%), they tend not to adopt these methods to the same extent as do all U.S. women during the early reproductive years, when education and employment are critical to socioeconomic attainment.

PIP: Researchers compared data from 1985 on 1998 15-49 year old Puerto Rican women living in the greater New York City area with data from 1982 on 3174 15-49 year old women living in Puerto Rico and with data from 1982 on 7969 15-44 year old women living in the US to examine their contraceptive practices. Women who were born in Puerto Rico and later lived in New York City had almost the same sterilization rate as those women still living in Puerto Rico (44.7% vs. 40.5%). On the other hand, about the same proportion of Puerto Rican women born and raised in New York City used reversible methods (42.1%), especially oral contraceptives (18.5%) and the IUD (11%). Only 18.5% of the US-born Puerto Rican women had undergone female sterilization which basically equalled that for all US women (18.7%). A higher proportion of Puerto Ricans in New York City used reversible methods than did those in Puerto Rico (21.7% vs. 15.7%), but not as high a proportion as all US women (36.8%). US-born Puerto Ricans did not accept reversible methods as early in the reproductive years as did all US women (42.2% vs. 58.4% for 15-24 year olds). Puerto Rican women, regardless of residence or place of birth, reported fewer male sterilizations and less condom use by their partners than all US women (0% male sterilizations for all Puerto Rican women in New York City, 4.6% for those in Puerto Rico vs. 10.8% and 2.8% of partners using condoms for island-born Puerto Ricans, 5.1% for US-born Puerto Ricans, and 4.4% for those in Puerto Rico vs. 9.8%). These findings on partner responsibility for contraception may reflect the cultural definition of women as rearers of children. The researchers hoped that the results of this descriptive study would motivate others to conduct further research to determine socioeconomic correlates of contraceptive practice and cultural and religious variables.

Survey report: Eastern Caribbean.

PIP: Over 1 million people live on 8 small islands in the Eastern Caribbean: St. Kitts-Nevis, Montserrat, Grenada, St. Vincent, Antigua, Barbados, St. Lucia, and Dominica. Starting in 1985 the International Planned Parenthood Federation, Western Hemisphere Region has carried out a series of contraceptive prevalence surveys in these countries. Current information is provided by these surveys in the areas of fertility levels and preferences, contraceptive knowledge and use. Also, socioeconomic, historical and demographic background and analysis such as fertility patterns, desire for additional children, and breastfeeding data; contraceptive awareness including family planning methods and sources; contraceptive use by method, source, and timing, satisfaction, and male attitudes are provided in the surveys, but not in the report abstracted here. The total fertility rate (TFR) and the contraceptive prevalence rate (CPR) for the 8 islands are as follows: St. Kitts-Nevis (1984) 2.9 TFR, 40.6 CPR; St. Vincent (1988) 2.9 TFR, 58.3 CPR; Antigua (1988) 1.8 TFR, 52.6 CPR; Barbados (1988) not given, 55.0 CPR; St. Lucia (1988) 3.2 TFR, 47.3 CPR; Dominica (1987) 3.2 TFR, 49.8 CPR. The islands have unusual demographic patterns related to extensive out-migration.^ieng

Survey report: Haiti.

PIP: Men, as well as women, were interviewed in the Haiti National Contraceptive Prevalence Survey (NCPS) in 1989. THe inclusion of males allowed the survey to: 1) attain information on fertility, contraceptive use and supply sources, method mix, and unplanned pregnancies; 2) explain the difference between the number used; 3) examine the role of men in family planning; and investigate barriers to contraceptive usage. The preliminary report of the survey found that the use of family planning among women in union (WIU) has gone up to 10%; use of traditional contraceptive methods is less than 1%. The pill is the most frequently used method (4% of all WIU); followed by female sterilization (2.5%), and the "injection" (16%). Less than 1% of WIU use condoms. Among men in union (MIU), 11% use family planning. Condoms are the most commonly used method (3.4% of MIU). Women may underreport condom use. MIU may report use of condoms with partners outside of their current union. Among all men, 8.5% use family planning; 6% of single men, mostly in urban areas, report using condoms. Most men say that they use condoms to prevent pregnancy; 13% use them for protection against sexually transmitted diseases, including the acquired immunodeficiency syndrome. Another 20% give both reasons. Among women and men in union who are using family planning, 2.3 gave reasons of infertility, sexual activity, or pregnancy. 37% of the nonusers are breastfeeding or pregnant; another 10% would like a pregnancy (18%); 16% of men believe their partner is menopausal. Among women who gave birth in the 5 years previous tot he survey, more than 2/3 has at least 1 antenatal care visit; 22% had more than 6 visits. 3 in 10 of these birth were not planned.^ieng

Survey report. Jamaica.

PIP: This article is a summary of the Jamaican Contraceptive Prevalence Survey (JCPS). As a brief survey report on Jamaica, it states the past fertility rates of Jamaica, the pertinent present fertility rates in correlation with family planning prevalence, and the health education levels of Jamaican women. JCPS found that the total fertility rate between 1983 and 1989 fell from 3.5 to 2.9 children per woman. More than 90% of women interviewed knew of modern contraceptive methods and 55% of all women in union are using contraception. Most mothers giving birth within the past 5 years received antenatal care and more than 90% were attended by health personnel. Nearly all women breastfeed offspring and the average duration is 13 months. About 2/3 received a tetanus injection. JCPS analyzed Jamaican women's knowledge of AIDS and 14% of these women self-assessed themselves as high risk individuals. Although most women correctly understood possible routes of AIDS transmission, misconceptions were common (e.g. 58% believe giving a blood donation is an AIDS risk, 35% thought insect bites could transmit the virus, 16% feared sharing personal items, and 8% said being in a room with an AIDS victim was a risk behavior).^ieng

Contraceptive use and fertility in Paraguay, 1987.

In 1987, 38 percent of married Paraguayan women aged 15-44 were practicing contraception, with oral contraceptives being the most prevalent method. Fertility rates for the population were at corresponding levels, with an overall fertility rate of 5.4 births per woman. Fertility has not changed substantially for the nation as a whole since 1979, and contraceptive use has increased by only 6 percentage points. Findings from the present study are consistent with the lack of a public sector family planning program in the country. Pharmacies are the principal source of contraceptives in the country. Twenty-two percent of all women and one-third of married women are at risk of having an unplanned pregnancy. The greatest impact on contraceptive use can be made if new and continued program efforts focus n the interior of the Oriental region of the country.

PIP: In 1987, staff from the International Planned Parenthood Federation affiliate in Paraguay (CEPEP) with technical assistance from the US Centers for Disease Control (CDC) selected 1500 households in metropolitan Asuncion and the interior of the Oriental region (the Interior) to study contraceptive behavior and fertility. Eligible respondents to the survey consisted of women 15 to 44 years old, regardless of marital status. Researchers interviewed only 1 woman per household and completed 2224 interviews. The 1987 overall fertility rate of 5.4 births per woman did not change much since 1979 (4.9), and contraceptive use only increased from 32.1% to 37.6%. Metropolitan Asuncion reported the highest prevalence (more than 50%). In terms of methods to control family size, oral contraceptive (OC) led the list of contraceptive use at 13.5%, followed by native herbs called yuyos at 7.2% and intrauterine devices (IUDS) at 5.1%. After the Paraguayan MOH stopped providing family planning services through MOH facilities in 1979, pharmacies became the primary source of contraceptives (51%). Prior to 1979, the MOH supplied 45% of all contraceptives. Findings in the survey indicated that 22% of all women and 33% of married women are at risk of having an unplanned pregnancy. Also the women exhibited a strong interest in spacing or limiting family size, but because the public sector does not provide contraceptives women cannot do so.

Brazil 1986: results from the Demographic and Health Survey.

PIP: The Brazil Demographic and Health Survey (DHS) was conducted by the Society for the Welfare of the Family in Brazil within the framework of the DHS Program of the Institute for Resource Development of Westinghouse. The survey is national in scope, covering 95% of the population. Data were collected in 8519 households and complete interviews were conducted with 5892 women aged 15-44. Fieldwork for the survey took place between May and August, 1986. The summary statistics presented here were taken from the Brazil First Country Report, with exceptions as noted. The summary statistics include: population characteristics, fertility patterns, fertility preferences, current contraceptive use, contraception knowledge, nuptiality and exposure-to-conception status, postpartum variables, infant mortality, disease prevention and treatment, and nutritional status.^ieng

Changes in contraceptive use and fertility: Panama, 1976 to 1984.

PIP: From 1976 to 1984 important demographic changes occurred in Panama. The total fertility rate declined from 4.5 to 3.7, and contraceptive use among married women 20-44 years of age increased from 55% to 63%. However, using data from 3 national level reproductive health surveys which were conducted in Panama in 1976, 1979, and 1984, we found that most of the changes took place between 1976 and 1979. Since 1979, overall contraceptive use and fertility have remained virtually unchanged, although there has been an important method-mix shift toward an increase in the use of contraceptive sterilization and IUD's, with an accompanying decline in the use of oral contraceptives. Although the singulate mean age at marriage remained relatively constant, the average duration of breastfeeding rose 23% during the period. Further gains in contraceptive prevalence and reduction in unplanned fertility in Panama will largely depend on enhanced program efforts 1st begun in the early 1970's by the Panama Ministry of Health. Future program efforts especially should be directed toward encouraging young couples to space their children more effectively by using temporary methods of contraception. The surveys used for this analysis were the 1976 Panama National Fertility Survey of the World Fertility Survey program, the 1979 Panama Contraceptive Prevalence Survey (Westinghouse), and the 1984 Panama Maternal-Child Health/Family Planning Survey.^ieng

Survey report: Ecuador.

PIP: The 1987 Demographic and Health Survey of Ecuador showed that total fertility rate has fallen, contraceptive prevalence is up slightly, female sterilization and IUDs are the most popular methods, but there is still a demand for more family planning services. The survey covered 4711 women aged 15-49, the 3rd poll since 1979. About half of the 10 million Ecuadorians live along the coast, most near the city of Guayaquil. The total fertility rate has fallen 19% from 5.4 to 4.3 births per women since 1982. The mean number of children born to women 45-49 years was 6.0, compared to 6.7 in 1979. 84% of women with 3 or 4 did not want more children; less than 50% of those with 2 or fewer did not want more. Contraceptive use rose from 40% to 44% since 1987. Pill use has declined for fear of adverse health effects. 34% of women using contraception have been sterilized, and 22% have IUDs. Use of natural family planning has risen to 14%. Only 18% of surveyed women knew of vasectomy, and only 47% were familiar with condoms. Low educational attainment was highly associated with non-use of family planning and recent diarrheal illness in children, variables linked to rural residence, low living standards, limited access to health services and poor health practices.^ieng

Survey report: Haiti.

PIP: With a population of 6.2 million, Haiti is one of the poorest, most densely populated countries in the Caribbean. According to a 1983 Contraceptive Prevalence Survey, fertility averages 6.2 children/woman compared with 6 children/woman in 1977. Moreover, the proportion of women in union practicing family planning declined from 14% in 1977 to 7% in 1983. Female sterilization increased slightly between 1977 and 1983, from 0.2 to 0.7% of women in union, but at the same time there were declines in the percentage of women using traditional methods such as withdrawal and rhythm as well as supply methods such as oral contraceptives and condoms. Concerns about health problems associated with use of the pill and the IUD were cited by many respondents in the 1983 survey as reasons for nonuse of modern methods. The increase in fertility has been created in part by a growing percentage of women in Haiti married or cohabitating. Of the 4321 respondents in the 1983 survey, 23% were married, 31% were cohabitating, and another 9% were in less stable unions. 10% of the formally married women and 7% of the women in noncohabitating unions used family planning compared with only 4% of cohabitating women. Women who had some secondary education were 2-3 times more likely to use contraception, while urban women had use rates twice those of rural residents. Another concern is the high infant mortality rate--107 deaths/1000 births in 1977--caused by poor sanitation and limited access to health services. 77% of Haitian mothers surveyed had given birth at home. 63% had received some prenatal care, but only 22% sought postnatal care. On the other hand, over 90% of the mothers breastfed their infants and over 80% of children over 5 years of age had been vaccinated against the major childhood diseases.^ieng

Contraceptive use and fertility in Honduras, 1981-84.

This paper presents data on contraceptive use and fertility in Honduras obtained from a household survey conducted in 1984, and compares these data with similar information obtained from surveys carried out in 1981 and 1983. About half of the increase that has taken place in contraceptive use in Honduras is accounted for by sterilization. In 1981, 27 percent of women in union aged 15-49 years were practicing contraception; in 1984, the percentage of those 15-44 was 35 percent. The increase in urban areas was smaller (from 47 percent to 51 percent) than in rural areas (from 16 percent to 24 percent). Also, fertility remained almost unchanged in urban areas while declining in rural areas. Information from questions on place of purchase, price, and brand of contraceptive (for orals) was used to determine source of supply. The use of multiple questions to determine source results in a higher percentage of contraceptive use attributed to the Honduran Family Planning Association as compared with answers to a single question. The duration of breastfeeding in Honduras has increased, with the greatest changes occurring among women in urban areas and women with the highest levels of education. Efforts have been made to promote breastfeeding in urban areas and these results suggest that the efforts have been successful.

Survey report: Barbados.

PIP: In the course of the 1980 Contraceptive Survey carried out in Barbados, 1500 men aged 15-49 were interviewed. The percentages using family planning were greatest for men in a formal marriage (57%) and lowest for those living with a women (45%). However, there were larger differences in the type of contraceptive used depending upon the type of conjugal relationship. 20% of the men in a visiting relationship used the condom compared with only 9% of married men. In contrast, only 2% of the men in visiting relationships had a sterilized partner compared with 16% of married men. Men were also asked to give their attitudes toward women, pregnancy, and family planning in an effort to examine attitudes that might affect the fertility of their sexual partners. About 43% of the men thought that women;s status was equal to men's, and 69% agreed it ought to be. More educated and married men were most likely to think that women held a lower status than men. The men wanted an average of 2.1 children, close to the current actual fertility rate. There was little difference by age, education, or other background characteristics. The men agreed that young girls were having babies too early reflecting a nationwide concern about teenage pregnancies. Age 19 was considered the optimal age for beginning a visiting relationship, but the men surveyed felt that marriage should wait until the age of 28 on the average. About 1/2 said that contraceptive decisions should involve both partners.^ieng

[Reproduction and contraception. Third National Prevalence Survey 1986]. / Reproduccion y contracepcion. Tercera Encuesta Nacional de Prevalencia 1986.

PIP: Preliminary results are presented from the Third National Contraceptive Prevalence Survey of Colombia, which took place in 1986. The sample of about 4500 households was representative on the national, urban, rural, and regional levels. The total fertility rate for 1986 was estimated at 4.9 in rural areas, 2.8 in urban areas including Bogota, and 3.2 for the country as a whole, compared to 4.4 in 1976 and 6.7 in 1969. Fertility changes in women over 30 have been particularly important in the past 10 years. The number of live births per 1000 women declined from 233 in 1971-75 to 183 in 1981-86 for women aged 20-24, from 227 to 173 for women aged 25-29, from 176 to 122 for women aged 30-34, from 131 to 79 for women aged 35-39, and from 67 to 30 for women aged 40-44. 69% of women in unions did not want more children. 30% of those aged 15-19 did not want more children and 29% did not want more for at least 2 years. 98% of Colombian women knew of some contraceptive method. 82.6% of women currently in union have used a method and 63.2% were using a method at the time of the interview. 51% used a modern method. The pill was most often used by younger women, the IUD by slightly older women, and voluntary sterilization was preferred by women over 30. Women using IUDs tended to be better educated and to live in urban areas. 24% of women in union in Bogota used IUDs in 1986. Sterilization was more prevalent in the Atlantic region and in less educated women. Contraceptive usage increased from 43% to 63% of women in union between 1976-86. 18% of Colombian women were sterilized as of 1986. PROFAMILIA clinics are the most important source of IUDs and female sterilization, while drugstores and pharmacies are the most important source for pills, vaginal spermicides, condoms, and injectables. 31% of women who stated they wanted no more children were not using any family planning method. The unsatisfied need was greater for younger women, the less educated, rural women, and those in the Atlantic region.^ieng

[Survey of men provides reliable data on contraception in the Dominican Republic]. / Encuesta de varones proporciona datos confiables sobre la anticoncepcion en la Republica Dominicana.

PIP: Comparison of the results of 2 contraceptive prevalence surveys in the Dominican Republic, 1 of a sample of 4741 women in 1983 and the other of a sample of 4203 men in 1984, indicated that men and women have similar levels of knowledge and reported similar levels of use of contraceptives. Differences were noted in such areas as the acceptability of methods and the number of children each spouse desired. Both surveys were conducted by the National Council of Population and the Family. The women were aged 15-49 years and the men were 15-59. 2037 of the men were in union at the time of the survey and 2166 were single. The majority of respondents in both groups were under age 30. 44% of the men and 29% of the women under 30 were single. Dominican men are 5-10 years older than women on average when they enter stable unions. A comparison of age specific fertility rates of men and women showed that men have their highest level of fertility between 25-30 years and continue to reproduce beyond age 50, while women's fertility is highest between the ages of 20-29 and declines considerably thereafter. The total fertility rate was 4.2 for men aged 15-49 and 4.6 for men aged 15-59. It was 4.1 for women aged 15-49. Over 1/2 of men and 1/2 of women in union who had 2 or more children stated they wanted no more children, but at each parity men were more disposed to want another child. Women at all parities overestimated the number of children their partners wanted. The pill was the only contraceptive method that the majority of men and women who had ever been in union named spontaneously. When other methods were named, 94% of men and 97% of women ever in union knew about pills and female sterilization, 71% of men and 89% of women knew about IUDs, 71% of men and 80% of women knew about injectables, and 61% of men and 75% of women knew about vaginal methods. 92% of men and 88% of women knew about condoms. 46% of the women in union had been using a family planning method, including 27% who were sterilized and 9% who used pills. The responses of men when asked about their wives' contraceptive use were about the same. However, men reported higher use of male methods. 9% of men but only 1% of women reported using rhythm, 7% of men but 3% of women withdrawal, and 5% of men and 2% of women condoms. Among men not using a method, 61% reported they might use rhythm, condoms, withdrawal, or vasectomy in the future. 94% of men approved of at least 1 female method, but approval of specific methods varied widely. Over 80% of men in union approved of female sterilization and rhythm, but only 37% approved of pills and 41% of IUDs. The researchers concluded that men cooperate sufficiently to justify similar surveys in other Latin American countries, and that men can be reliable sources of information for programming and evaluation of family planning programs.^ieng

Barriers to modern contraceptive use in rural Peru.

This paper examines Quechua-speaking Indians' choice of contraceptive methods and discusses barriers to the use of modern contraceptives. A study conducted in a Peruvian highland community shows that contraceptive choice is strongly related to a couple's life experiences, their contact with urban centers, their economic status, and their emphasis on cultural values. Among contraceptive users, husbands are concerned with family size and encourage their wives to seek information about the use of modern contraceptives. A discrepancy in attitudes exists between spouses: the men's positive attitude toward modern contraception contrasts with the women's traditional desire for a large family. In this study population, modern contraception is a novelty that has reached only a few families. The majority of the couples practice natural and traditional family planning methods, which are not reliable. Villagers do not use modern contraceptives as a result of cultural barriers created by family planning services that do not take into account the lifestyle of these people, insufficient knowledge of human physiology, comments from dissatisfied users, and women's reliance on their reproductive role for self-esteem.

PIP: This paper, based on fieldwork done in 1984 in a Peruvian highland community with a population of about 3,500, examines Quechua-speaking Indians' choice of contraceptive methods and discusses barriers to the use of modern contraceptives. The village is poor, with many of the villagers involved in migrant labor, but there have been modernization influences: most villagers are bilingual, men average 8 years of schooling and wives 6. Government family planning programs (FP) were initiated at the local health post in 1982. This study, sampling 54 couples, 2/3 in consensual unions shows 1st pregnancy is usually at 18, and about 5 live births take place by age 31. Only 12 couples reported not using any form of contraception, 27 unreliable natural or traditional methods, and 15 modern methods. Non-contracepting women tended to breastfeed longer and have less schooling, and tended not to be working full-time. Contraceptive choice is strongly related to a couple's life experiences, their contact with urban centers, their economic status, and their emphasis on cultural values. Among contraceptive users, some husbands are concerned with family size (for economic, child welfare, and health reasons) and encourage their wives to seek information about the use of modern contraceptives. A discrepancy in attitudes exists between spouses: men's positive attitude toward modern contraception contrasts with women's traditional desire for a large family. Villagers do not use modern contraceptives because of barriers created by FP services that do not take into account the lifestyle of these people (e.g. language, work hours, respect for privacy), disturbing and poorly explained side-effects, especially of pills and injected depo-provera, insufficient knowledge of human physiology, contraception failures due to inappropriate use (often because of poor explanations by health post staff), comments from dissatisfied users, and women's reliance on their reproductive role for self-esteem.

Side effects and discontinuation of oral contraceptive use in southern Brazil.

PIP: Oral contraceptives have many advantages, but sometimes also have side effects which can cause users to switch appropriately or inappropriately to less effective methods or abandon contraception. In Brazil, 2/3 of married women of childbearing age were using contraception in 1981, and 1/2 of these were using orals. Contraceptive behavior following reported side effects in users of oral contraceptives in Southern Brazil is examined in this study, in relation to diverse factors. Among 2904 currently-married women, aged 15-44, almost 75% reported that they had used the pill at some time, and of these, 45.6% were still doing so. Data on perceived side effects were gathered for all women. There was no independent medical evaluation of the effects, so the data did not necessarily represent actual prevalence of pill related problems. Women who reported problems with the pill were less likely to be current users (25%) than women who did not (65%). However, overall contraceptive prevalence was about the same in both groups (66.2% and 67.0% respectively), indicating that women who stop using oral contraceptives usually switch to another method. However, they are more likely to be using traditional methods than women in the general population, especially if they want more children. Termination of pill use varies little according to the type of problem reported. Women with problems who sought medical attention were more likely to stop using the pill, and 82.4% of women advised to stop by their physician did so, but the major factor affecting discontinuation was the reported experience of a problem. The most frequently reported problems were headaches (38.1%), nausea (34.1%), nervousness (27.9%), and vertigo (18.3%). Physician intervention should help to avoid women's abandoning oral contraceptives unnecessarily.^ieng

[Sterilization determinants and their demographic effect on Colombia and Costa Rica]. / Los determinantes de la esterilizacion y su efecto demografico en Colombia y Costa Rica

PIP: This article is based on data gathered during contraceptive prevalence surveys carried out in Costa Rica and Colombia in 1978, and in 1980 in Colombia and 1981 in Costa Rica. The groups studied consisted of women aged 14-49, and ranged in population from n=3,400 to n=4,580. Colombia Ministry of Health policy limits access to sterilization to couples over 30 with at least 3 children. Profamilia, private family planning organization, has similar though less stringent norms. The majority of sterilizations are of females. Sterilization has come under some attack by the Roman Catholic church, family planning programs continue to be viable. In Costa Rica, sterilization has not been practiced as a family planning method officially, but was performed by the national social service system as well as private providers when it was medically indicated. Since 1982, sterilization has been illegal in Costa Rica. Comparing the 2 countries, the Colombian sterilization rate rose from about 17/1000 ever married women in 1970 to 19.8 in 1980. The rate for Costa Rica rose to 21.6 in 1976, after which there was an attempt to restrict the practice. The effects of the restriction had become negligible by 1980. Women married for 19-20 years were the group with the highest % of sterilizations in both countries. Women with 6 or more live children in Costa Rica, and 4 in Colombia, women 30-39 in Colombia and 35-44 in Costa Rica, women having previously used contraceptives and women in urban areas were more likely sterilized. It is projected that a high potential demand for sterilization exists in Colombia, but the demand in Costa Rica is considerably less. The acceptor characteristics (e.g. years married, age) are quite similar for the 2 countries. Generally speaking, fertility is higher among sterilized women in both countries.^ieng

Contraceptive prevalence in the slums of Rio de Janeiro.

A community-based family planning operations research project was undertaken in selected low income communities of Rio de Janeiro; project field work began in February 1982. Prevalence data were collected and service delivery strategies were tested, including home visits promoting family planning, home distribution of condoms, and the introduction of community family planning depots. A high baseline contraceptive prevalence rate (CPR) of 70.1 percent was found for nonpregnant women currently in union, as well as substantial use of the private sector for contraceptive supply, despite the presence of free or subsidized sources within the communities. However, the most economically disadvantaged subgroups made the greatest use of the subsidized sources. The provision of additional service delivery sites may have contributed to a small increase in contraceptive prevalence noted over the life of the project; however, the high baseline CPR precluded a large increase in contraceptive use as a result of the program.

PIP: A community-based family planning operations research project was undertaken in selected low income communities of Rio de Janeiro; this activity represented the 1st attempt to obtain contraceptive prevalence data in fanelos (slums) of Rio. Project field work began in February, 1982. Prevalence data were collected and service delivery strategies were tested, including home visits promoting family planning, home distribution of condoms, and the introduction of community family planning depots. A high baseline contraceptive prevalence rate (CPR) of 70.1% was found for nonpregnant women currently in union, as well as substantial use of the private sector for contraceptive supply, despite the presence of free or subsidized sources. 4800 women between the ages of 15 and 44 years of age were interviewed for the baseline survey. 4442 women were reinterviewed at follow-up, 3600 of whom were nonpregnant women currently in union. Contraceptive prevalence at follow-up among this latter group was 4.6% higher than at the time of the baseline survey. The proportions of women using each source of contraceptive supply remained fairly stable between the baseline and follow-up surveys. The data suggest a small switch from a temporary to a permanent method of family planning, associated in part with the increases in age and parity between the baseline and the follow-up surveys. The provision of additional service delivery sites may have contributed to the small increase in contraceptive prevalence noted over the life of the project; however, the high baseline CPR precluded a large increase in contraceptive use as a result of the program. The operations research data thus suggested that continued home visits would not be cost effective in the communities included in the study.

Contraceptive use and fertility in Guatemala.

In 1983, one-quarter of married Guatemalan women aged 15-44 years were using contraception, and female sterilization was the most prevalent method. Fertility rates for the population were at correspondingly high levels, with an overall total fertility rate of about six births per woman. Contraceptive prevalence varied by residence and ethnic group; less than 5 percent of currently married Indian women and about 50 percent of married women in the capital city area were using contraception. From 1978 to 1983, prevalence increased overall by six percentage points, with surgical contraception accounting for most of the increase. Findings of the study suggest that different strategies need to be employed among Ladino and Indian women in order to increase contraceptive prevalence in these subgroups.

PIP: A 1983 survey shows that Guatemala continues to have a relatively low level of contraceptive use by Latin American standards. However, by comparing the results of the 1983 survey with those of a similar survey conducted in 1978, it is clear that contraceptive use has increased slightly. During the 5-year interval between these surveys, the % of married women aged 15-44 years old who were using contraception increased from 19 to 25%. Most of the increase in prevalence was in the use of sterilization, which was found to be the most prevalent method in both surveys. This report describes the results of the 1983 Family Planning and Maternal/Child Health Survey conducted in Guatemala. Also discussed are trends in fertility, breastfeeding, contraceptive use, source of contraception, and women at risk of unplanned pregnancies since the 1978 survey. The 1983 data indicate that mean parity was higher for Indian women than for Ladino women at every age above 20. The mean parity for all women in the 1983 survey is slightly less than that of women in the 1978 survey, but of generally the same magnitude. Overall, the mean duration of breastfeeding estimated from the 1983 survey is 18 months. Postpartum amenorrhea averages about 12 months for all groups. A comparison of duration of breastfeeding for respondents in the 1978 survey with those in the 1983 survey provides no evidence of a trend away from breastfeeding in Guatemala. Overall, 1/4 of married women aged 15-44 were using contraceptive methods at the time of the 1983 survey. The most prevalent method was female sterilization (10%), which, together with male sterilization, accounted for 45% of all contraceptive use. The 2nd most commonly used method, oral contraceptives, had a relatively low prevalence of 5%, followed by rhythm, the IUD, injectables and vaginal methods, and finally, the condom. Contraceptive use also varied by age, reaching a peak among married women 30-39 years old and was lowest for those 15-24. Use of contraception was strongly related to education, being lowest among women with little or formal education. Results in general suggest that contraceptive use is part of a larger predisposition among women to use modern health care. Among Indians, the major reason given for nonuse of contraceptives unrelated to pregnancy was lack of knowledge of contraception or where to obtain family planning services. Among Ladinos, the most frequently mentioned reason was fear of contraception or fear of side effects. The methods of choice for nonusers desiring to use a method were oral contraceptives (27%), sterilization (18%) and injectables (14%). The survey data indicate that the family planning program in Guatemala should be oriented toward high parity, married, nonworking women living in the interior, both Ladino and Indian, who have less than a primary school education. Family planning efforts need to incorporate different approaches for Ladino and Indian women.