Associations between contraceptive availability and rate of subsequent legal abortions in Colombia: A historical cohort analysis.

OBJECTIVE: To describe factors associated with subsequent abortions in Colombia and evaluate whether high-efficacy contraceptive availability (IUD) post-index abortion was associated with higher efficacy contraceptive initiation and fewer subsequent abortions within 2 years. METHODS: The study population comprised patients aged 15-44 years who underwent index abortion in 2017 at four clinics in Bogotá, Colombia. Using charts, we conducted a retrospective cohort study with 2-year follow-up (2017-2019) after the index abortion for outcomes of contraceptive initiation and subsequent abortion. We evaluated associations between demographic or clinical characteristics and outcomes using Pearson chi-square and multivariate logistic regression. RESULTS: Of 9175 patients with index abortion, 3409 (37.2%) initiated an intrauterine device (IUD) and 467 (5.1%) had a subsequent abortion within the study period (2017-2019). IUD availability (adjusted odds ratio [aOR], 1.64; 95% confidence interval [CI], 1.39-1.93) and insurance use (aOR, 5.03; 95% CI, 4.37-5.78) were associated with high-efficacy contraceptive initiation; medication abortion was inversely associated (aOR, 0.24; 95% CI, 0.22-0.27). Initiation of no (aOR, 4.94; 95% CI, 3.59-6.80) or moderate-efficacy (injection: aOR, 4.21 [95% CI, 3.14-5.62]; oral contraceptive pill: aOR, 4.60 [95% CI, 3.21-6.59]) methods were associated with subsequent abortion. CONCLUSION: Subsequent abortion is inversely associated with initiated postabortion contraceptive efficacy, which is modifiable on a systems level by improving access to effective postabortion contraception.

Marketing social marketing to commercial partners: what's in it for them?

PIP: Commercial partnerships in social marketing have grown increasingly important in the context of diminishing resources from international donors in developing countries. In 1997, the Futures Group International (Futures) negotiated an agreement with Pharmacia & Upjohn/Brazil to introduce Depo-Provera, a 3-month injectable contraceptive, at a social marketing price with strong consumer marketing support. The key to the collaboration was to demonstrate that making Depo-Provera accessible to low-income consumers was a viable marketing strategy. The author describes the process of designing, negotiating, and implementing the successful commercial partnership. Brazilian women stand to gain the most from the partnership between Futures and Pharmacia & Upjohn/Brazil, for in the absence of such a coordinated effort, Depo-Provera would be available to only upper-income, breast-feeding women whose only source of information on the method would be private physicians. The partnership will bring Depo-Provera to a broader segment of Brazil's women.^ieng

Disparities in access to family planning services in Jamaica.

In order to improve the effectiveness and subtainability of the family planning programme, the National Family Planning Board has devised a strategy to shift users to longer-acting methods and increase the role of the private sector. To design interventions, a better understanding of existing services was thought to be necessary. This study examines the distribution of family planning service delivery points in Jamaica and the services offered by the public and private sectors through an examination of records and questionnaire interviews. The study found that, because of the concentration of private sector providers-the main outlets for longer-acting methods-in urban areas, rural areas had poor access to these methods. Because rural areas are not attractive to private sector providers, the public sector should recognize the need to continue to serve these areas.

PIP: Jamaica's National Family Planning Board's strategy to ensure the sustainability of its family planning program and improve its effectiveness involves getting users of contraception to use longer-acting methods and increasing the role of the private sector in service delivery. Before this approach was implemented, however, a study was conducted to secure a better understanding of the nature and scope of existing family planning services in Jamaica. The study looked at the distribution of family planning service delivery points in Jamaica and the services offered by the public and private sectors through an examination of records and questionnaire interviews. Private sector providers, the main sources of longer-acting methods, were found to be concentrated in urban areas. As such, longer-acting methods were hard to come by in rural areas. The public sector must recognize that private sector providers are not serving rural areas, and provide longer-acting methods to people who want them.

Brazil assessment finds unmet needs in the public sector.

PIP: An assessment conducted in municipalities in four of Brazil's nine states in 1993 revealed high rates of unwanted fertility. As many as 58% of pregnant women reported that their current pregnancy was either unwanted or mistimed. Despite Ministry of Health approval for the provision of oral contraceptives, IUDs, condoms, spermicides, diaphragms, and natural family planning methods, public-sector programs generally offered a limited range of contraceptive options and frequently were out of supplies. Also observed by the assessment team was a strong medical (as opposed to primary health care) orientation among contraceptive providers and a lack of training of physicians and nurses in family planning. On the basis of this assessment, the team recommended that efforts be directed toward strengthening the provision of methods that are often unavailable (e.g., IUDs, barrier methods, and lactational amenorrhea) rather than expanding contraceptive options. Research currently underway in Sao Paulo state seeks to identify the operational and management changes necessary to broaden contraceptive choice and improve the quality of reproductive health services. A data collection and information retrieval system has been set up to record health post activities, and a family planning training and referral system has been established. The Brazil assessment was conducted according to a three-stage model devised by the UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction.^ieng

Cuba: plenty of care, few condoms, no corruption.

The health system in Cuba guarantees accessibility to the entire population, is free of charge, and covers the spectrum from vaccinations to sophisticated interventions. The results are impressive: Cuba's health figures are on a par with developed countries that have 20 times the budget. The country is experiencing a difficult period because of the collapse and loss of support from the Soviet Union; over 30 years' trade embargo by the United States; and the gradual change from a centrally planned economy towards more of a free market system. Shortages are experienced in every sector, and maintaining health care services at the current level is too expensive. Doctors and nurses continue to work towards the goal of health for all Cubans, even though their salaries are minimal. Signs of negligence or corruption, often seen in other socialist countries where incentives for output are lacking, are unknown. Topics such as family planning and AIDS deserve immediate attention.

PIP: The health system in Cuba guarantees accessibility to the entire population, and it is free of charge. Cuba's health figures are on a par with developed countries that have 20 times the budget. Each year around 4000 students start their medical training at 23 different universities. Since 1980 there has been a training course for family doctors. By 1995 22,000 of them have been trained covering 90% of the population. Their main work is preventive: health promotion and offering basic curative care. The family doctors are backed up by 400 polyclinics, where specialists offer their services to about 30,000 people. Life expectancy is 77 years and infant mortality a mere 9 per 1000 live births. Malaria has been eradicated and dengue fever successfully reduced. Leading causes of mortality are cardiovascular diseases, neoplasms, accidents, and homicides. Up to now only 1089 people have been diagnosed as HIV positive. From a mere epidemiological point of view, strict isolation could contain the epidemic in a closed society. In practice, however, the island opened the doors to tourism, with a side effect of increasing prostitution. Condoms or any contraceptives are in short supply. Nevertheless, the number of abortions is low, less than 1 per 100 deliveries. The reason is that all women whose expected menstruation is late by two weeks are offered a microaspiration in the polyclinic. 700 regulations are performed for every 5000 fertile women. Pregnancy tests are not performed as they are not available. The country is experiencing a difficult period because of the collapse and loss of support from the Soviet Union; over 30 years' trade embargo by the United States and the gradual change from a centrally planned economy towards more of a free market system. Family planning and AIDS seem two topics that need further exploration. Even if their system is under strain, health indices do not show a deterioration in health yet.

[Women in the labor force and migration. The female labor market between 1950 and 1990 and female migration to Santiago, Chile]. / La mujer en el trabajo y la migration. El mercado laboral femenino entre 1950 y 1990 y la inmigracion de mujeres a la ciudad de Santiago de Chile.

"This article examines the relationships between changes in the volume, relative importance and growth rates of female migration to Santiago [Chile], and modifications in the structure of the female labour market during the past four decades. It also analyzes changes in the characteristics of occupational insertion of migrants as compared to non-migrant women." The author investigates the impact of modernization, education, access to contraceptives, rural labor markets, and development strategies. (SUMMARY IN ENG)

Increasing FP access in Brazil.

PIP: A 1979 survey of women aged 15-45 years from Sao Paulo, Brazil, concerning their contraception use demonstrates the impact of family planning, even without an official family planning program. 23% of the women were using the pill and 16% were sterilized. Very few used diaphragms, condoms, or IUDs. Although there is now an official family planning program in Brazil, only middle and upper class women have access to sophisticated means of birth control. Poor women are limited to tubal ligation which is often disguised as a cesarean section (the rate at some hospitals for this operation is 90%). Since the Integrated Project was introduced in 2 pilot areas in 1983, 12 branches, where community representatives run monthly discussion meetings and classes are held on family planning methods, have been established in the city. Nurses coordinate volunteer efforts. The program began in slum areas by utilizing the nurses and nurseries already in place to care for children of working women. New expansion will require integrating the family planning program into other established, nongovernmental organizations and working with municipal and state governments.^ieng

[Badly resolved triad: sexuality, contraception and pregnancy]. / A triade mal resolvida: sexualidade, anticoncepcao e gravidez. Editorial.

PIP: Sexuality, contraception, and pregnancy are inseparable, yet they are a taboo subject both for the whole country and for adolescents. The ever-earlier awakening of sexuality requires educational mechanisms that assign fundamental importance to the implementation of social, psychological, and cultural protection strategies. The resolution of pregnancy is dependent on income just as maternity is secondary to financial independence. The majority of rich adolescents get an abortion, while poor adolescents carry to term their undesired pregnancies. Adolescence is a phase of confusion with peculiar psychosocial and cultural aspects. In the low-income population the start of formal education is precarious and delayed, an important factor in the discrepancies between well-to-do and poor social classes. Pregnancy and abortion rates vary according to economic conditions, however, their resolution clearly shows ethical, religious, and moral subjectivity. The media, rural exodus, increasing urbanization, and the economic crisis make maternity a less dominant aspect of women's lives. Young people do not obtain the necessary information for safeguarding their fertility because of the lack of specialized services, thus they are uncertain about what the health care system can provide. Much opportunity is lost because professionals are too busy or too disinterested to listen to these alienated youngsters. Preconceived notions, disinformation, and uncertainty coupled with emotional obstacles and noncooperation of the partner result in the use of contraceptives becoming a complex and difficult problem to resolve. It is necessary to alter our perceptions of adolescent sexual development. In Brazil, where more than half of the population is young, it is indispensable to devise collective programs not restricted to conventional medical practices to reach all adolescents.^ieng

Preventing HIV transmission in "priority" countries.

PIP: A recent $168 million 5-year cooperative agreement funded by the US Agency for International Development combines elements of its earlier AIDSTECH and AIDSCOM projects under the AIDS Control and Prevention Project (AIDSCAP). Instead of working to effect broad-scale behavior change toward the prevention of HIV transmission, AIDSCAP strategically targets locations for condom distribution, behavior change messages, and the treatment of sexually transmitted diseases. In Lagos and the states of Cross River and Jigawa where the AIDS epidemic is firmly established, for example, AIDSCAP is intervening to increase condom demand and accessibility; alter sexual behaviors which carry a high risk for HIV transmission; and reduce the prevalence of STDs which enhance the transmission of HIV. The project began in fall of 1991 and has expanded to include Ethiopia, Kenya, Malawi, Nigeria, Rwanda, Senegal, Brazil, Haiti, Jamaica, India, and Thailand; limited assistance is also provided to 7 other African countries, 4 Latin America countries, and 1 in Asia. 4 more countries are in the final stages of negotiations to be included in the project. The USAID mission in the host country and the government must invite AIDSCAP involvement in order for the country to attain priority status. Countries are selected based on the HIV prevalence rate, population size and distribution, level of commitment to HIV prevention/control, capacity to respond to the AIDSCAP plan of action, level of other donor support, the USAID Mission's development priorities, and the Mission's commitment of substantial funds from its own budget. Once involved, AIDSCAP is mandated to implement interventions through in-country agencies.^ieng

[Family planning in the guidelines of the National Congress]. / Planejamento familiar em pauta no Congresso Nacional.

PIP: In Brazilian Congress, the importance of family planning has, for historical reasons, been confused with controlling population growth. The question is mostly related to the iniquitous distribution of wealth rather than overpopulation. The populations of developed countries consume energy, primary materials, and foodstuffs for a comfortable living, however, a large part of the populations in countries on the peripheries barely survive with incomes below the poverty line. In Brazil, the richest 10% possess half of the national wealth, and the remaining 90% are left with the other half. Most of all, the lack of access to produced wealth is the reason why the majority do not have access to health care, education, leisure, information, culture, and the conditions of living with dignity. The adoption of contraceptive methods is intimately associated with the level of culture and information of the population. The majority of women desire to use some kind of contraceptive method. It is imperative that the state grant to the women and men who so desire access to the materials and necessary information in order to choose the number of children they desire. The Ministry of Health has run for almost a decade a program for maternal health (PAISM), although it has not been fully implemented, and the benefits of this program have remained inaccessible to large numbers of women, especially in the large metropolises. In Brazil, about 30% of women of reproductive age undergo sterilization, as opposed to only 7% in developed countries. Those who cannot afford it give birth to children who grow up without education or medical care and become immersed in violence to fight for their survival.^ieng

Impact of social marketing on contraceptive prevalence and cost in Honduras.

In 1984, the Honduran Family Planning Association launched a contraceptive social marketing program by introducing the oral contraceptive, Perla. This report examines the impact of the program on overall oral contraceptive use, use by particular subgroups, source of supply, and costs. Although use of oral contraceptives increased only slightly over the period 1984-87 (from 12.7 percent to 13.4 percent among women in union aged 15-44), the social marketing program significantly increased its share of the oral contraceptive market (from 7 percent in 1984 to 15 percent in 1987, and from 20 percent to 40 percent of sales at pharmacies). For the Honduran Family Planning Association to have realized cost savings as a result of clients switching from community-based distribution programs and commercial supply sources to contraceptive social marketing programs, the association would have had to reallocate its resources. Instead, the number of distributors in the community-based distribution program increased, while the amount of couple-years of protection from oral contraceptives decreased.

PIP: Researchers used data from 2 national surveys of maternal-child health and family planning (1984 and 1987) and from a 1989 study of economic costs by method and program to examine the impact of the contraceptive social marketing program of the Honduran Family Planning Association (ASHONPLAFA). ASHONPLAFA launched the program in 1984 by introducing the oral contraceptive (OC) Perla. Between 1984 and 1987, OC use increased minimally (12.7-13.4% among 15-44 year old women in union), yet the contraceptive social marketing program increased its share of the OC market (7-15% overall, 20-40% at pharmacies). The analysis showed that costs to ASHONPLAFA would fall if more women bought OCs from the contraceptive social marketing program instead of the community- based distribution (CBD) program, and if the resources earmarked to the CBD program in urban areas decreased. Yet, the number of distributors in the CBD program in urban areas actually increased, so ASHONPLAFA did not achieve cost savings. Further, the amount of couple-years of protection from OCs fell. The findings showed that market forces did not work and may not do so in like programs, where profit is not a goal and managers are not held accountable for cost increases. They also indicate that, in urban areas, the contraceptive social marketing program can serve more clients and the CBD program can be cut back. Further research is needed to examine whether and by how much ASHONPLAFA could reduce the CBD program without losing clients.

[Family planning among lower status women in Rio de Janeiro city]. / Planejamento familiar em mulheres de baixa renda no Municipio do Rio de Janeiro.

PIP: The National School of Public Health aided by WHO conducted a survey between 1984 and 1985 in 7 communities of Rio de Janeiro, Brazil, enlisting 1900 women aged 15-49 from 2019 households selected. 1783 were interviewed, yielding a response rate of 92%. 538 (30%) women were single, 7.2% of who had no sexual experience. 4.5% of the sample were widowed, divorced, or separated. Their familiarity with contraceptives was as follows: oral contraceptives, (OCs) 99.7%; female sterilization and the condom, 90%; coitus interruptus and vasectomy; 33%; the diaphragm, 27%; and natural methods; 22%. 83% of the women used OCs; less than 20% used the condom, coitus interruptus, or spermicides; and 5% had used the IUD. 8% of those 40 decided on tubal sterilization. 67% of the women in sexual unions used contraceptives vs. 35% of single women with sexual activity. Nonuse increased after age 35, while more than 50% of women 20 did not use contraceptives. Half of the sterilized women underwent the procedure before age 30 when they had 4 children. 66% of ligations were done during birth, and accompanied 63% Cesarean section. Only 28 of sterilizations were done by laparoscopy on another occasion. Misinformation about sterilization was rife, as 15% of sterilized women states that they wanted to bear a child in the future, and 11% thought that they could get pregnant. 42% of women aged 35 and over were sterilized by laparoscopy. In hospitals and clinics the average sterilized woman was 29.4 years old and had 3.5 children. Contraceptive prevalence was higher than the national average, it was comparable to the level in countries that have traditionally low fertility. The fact that OCs, the pill, and tubal ligation made up the predominant pattern of contraceptive use is the result of the inability of the health care system to provide an integrated family planning program with education about and provision of contraceptives.^ieng

Paraguayan pharmacies and the sale of pseudo-abortifacients.

This study was conducted in 1985 in Asunción, Paraguay, 6 years after the closure of the state supported family planning services. Data from national surveys in 1977 and 1987 permit a comparison of sources of contraceptive supplies before and after the elimination of government support for family planning. The purchase of pseudo-abortifacients from private pharmacies was used as an indication of induced abortion. After the loss of government clinics, it is suggested that some women turned to pharmacists to obtain pseudo-abortifacients when faced with unwanted pregnancy. There is an indication of increased pseudo-abortifacient use, particularly among unmarried women and those from poorer neighbourhoods.

PIP: The hypothesis that a restriction of family planning services will be associated with an increased incidence of abortion was investigated in a survey carried out in Asuncion, Paraguay, in 1985. In 1979, the Government of Paraguay abruptly eliminated all support for family planning services at Ministry of Health clinics--a measure that affected at least half of all contraceptive acceptors and forced them to turn to pharmacies for contraceptive supplies. The survey, which samples 10% of the registered private pharmacies in Asuncion, used the sale of pseudo- abortifacients as a measure of induced abortion. Also interviewed were 56 contraceptive purchasers and 51 purchasers of injectables contraceptives intended for use as abortifacients who were recruited at the participating pharmacies. The results indicated that low-income women were 5 times more likely than their higher income counterparts to purchase pseudo-abortifacients. In addition, unmarried women were 3 times more likely to purchase progestogen injections to induce a missed menstrual period than married women. Almost 70% of abortifacient purchasers reported that they had attempted to self-abort on previous occasions. The pharmacists stated that up to 50 women a week requested medication for pregnancy termination and were in agreement that this practice had increased substantially following the government's withdrawal of support for contraception. The pharmacists expressed concern about the nonavailability of counseling from trained family planning personnel and indicated that some pharmacy staff knowingly exploit women by injecting them with unsafe preparations or drugs that cannot induce abortion. The administration of ineffective pseudo-abortifacients can delay the decision to seek an illegal abortion or result in life-threatening incomplete abortion.

How to influence fertility: the experience so far.

PIP: Even though fertility in the US is 2, the population grows each year by 2.5 million people due to natural increase and immigration. The US has never had a formal population policy to influence its birth rate. Yet the US government advises other nations, especially developing nations, how they should go about reducing their fertility. Instead the US can learn from population policies of direct disincentives, such as no income tax allowance for 3 children. In Indonesia, the president and Islamic religious leaders strongly support family planning. In Mexico, both the public and private sectors provide family planning services. The US does not have experience in influencing fertility declines, since fertility declined due to economic development over a period of time. Some scholars claim that there are 3 preconditions for a sustained decline in fertility, all of which have significance for setting population policies. The 1st is called rational choice in which conditions are such in a society that women can make their own decision. For example, the existence of legislation that guarantees women the right to act in their own interest, including the right to make their own reproductive decisions. The 2nd involves policies or conditions that motivate individuals and/or couples to limit family size. Incentives and disincentives can provide the needed motivation. For example, the government pays a woman for not having a child for a specific interval. The last precondition includes the necessity of having means available to limit family size. These means include knowledge of contraceptive methods and accessibility to them.^ieng

Private sector joins family planning effort.

PIP: Projects supported by the Directorate for Population (S&T/POP) of the U.S. Agency for International Development and aimed at increasing for-profit private sector involvement in providing family planning services and products are described. Making products commercially available through social-marketing partnerships with the commercial sector, USAID has saved $1.1 million in commodity costs from Brazil, Dominican Republic, Ecuador, Indonesia, and Peru. Active private sector involvement benefits companies, consumers, and donors through increased corporate profits, healthier employees, improved consumer access at lower cost, and the possibility of sustained family planning programs. Moreover, private, for-profit companies will be able to meet service demands over the next 20 years where traditional government and donor agency sources would fail. Using employee surveys and cost-benefit analyses to demonstrate expected financial and health benefits for businesses and work forces, S&T/POP's Technical Information on Population for the Private Sector (TIPPS) project encourages private companies in developing countries to invest in family planning and maternal/child health care for their employees. 36 companies in 9 countries have responded thus far, which examples provided from Peru and Zimbabwe. The Enterprise program's objectives are also to increase the involvement of for-profit companies in delivering family planning services, and to improve the efficiency and effectiveness of private volunteer organizations in providing services. Projects have been started with mines, factories, banks, insurance companies, and parastatals in 27 countries, with examples cited from Ghana and Indonesia. Finally, the Social Marketing for Change project (SOMARC) builds demand and distributes low-cost contraceptives through commercial channels especially to low-income audiences. Partnerships have been initiated with the private sector in 17 developing countries, with examples provided from the Dominican Republic, Liberia and Ecuador. These projects have increased private sector involvement in family planning, thereby promoting service expansion at lower public sector cost.^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.

[On family planning policy in Brazil]. / Sobre a politica de planejamento familiar no Brasil.

PIP: Brazil's population could vary from a minimum of 164.5 million to a maximum of 183.5 million at the turn of the century. The increase in population is due essentially to a decline in mortality, since natality has remained steady, averaging 6.2 children/woman. During the 1st 4 years of the 1980s, a 19% drop in natality was registered, with the greatest reduction occurring in the East-Central (25%) region, testimony to an increased presence of highly effective contraceptive means. 65% of all married women between the ages of 15 and 44 use contraceptives, placing Brazil among the most developed countries (U.S.A., 68%). The main contraceptive method used is sterilization, preferred even by very young women, median age 29, as evidenced by a study in Sao Paulo. The choice of contraceptives, however, is limited. During the military dictatorship family planning was put in the hands of private organizations (BEMFAM since 1965, CEPAIMC since 1975) and recent policies have emphasized a hands-off attitude leaving birth control decisions to the family nucleus. The economic crisis, at the end of the 1970s, modified this position. In order to avoid that, only the wealthy classes have access to family planning means, the government increasingly plays an active role in providing information and assistance. A not-for-profit institution, ABEPF (Brazilian Association for Family Planning Entities), the largest of its kind in Latin America, organizes and promotes private initiative programs. Acting as a true syndicate, each clinic affiliated with the association receives training of professionals and equipment for installation of laboratories and consulting rooms. Various women's rights movements have been active and succeeded in influencing political parties.^ieng

[Questionnaire about contraceptive methods]. / Inquerito sobre o uso de metodos anticoncepcionais.

PIP: 500 sexually active women in Brazil aged 15-50 were interviewed to study their use of contraceptives. For the 350 who used contraceptives, the survey evaluated their level of education, marital status, incidence of pregnancy, and the number of abortions performed. The level of education had little effect on the choice of birth control methods. Women with 1 sex partner were more preoccupied with the use of birth control than women who had casual sex with more than 1 partner. The younger women in the group, whether or not they used birth control, had greater frequency of abortions. The preferred method of contraception was the pill, and of the women who took the pill, almost 1/2 did so without a doctor's prescription. 42% of the same group reportedf suffering side effects due to pill use. Since induced abortions are illegal in Brazil, it is certain that the information given is inaccurate. Other methods of birth control also had drawbacks. The early withdrawal method did nothing for the couple's sexual gratification, and was not an effective method of birth control. The rhythm method was rarely used, and could also be dangerous as far as effectiveness. The IUD, which has proven to be very effective in developed nations, was not widely used by this group because it was considered troublesome. It is clear from this report that all means need to be implemented to make birth control accessible to all levels of the population. Failure to utilize birth control methods on moral or religious grounds will cause an increase in abortions, many of which will be performed by unqualified people. The denial of birth control will lead to disastrous consequences.^ieng

[Weapon for planning]. / Arma para planejar.

PIP: Waldyr Arcoverde, the Minister of Health in Brazil, was cautious in his comments about the regulations regarding the manufacture of IUDs in Brazil, saying that "the IUD is just one more contraceptive method available." Yet, the IUD suggests many positives regarding the spread and acceptance of family planning in Brazil. The regulations permit in-country manufacture and remove the barriers and restraints that have made IUD insertion a semiclandestine activity in Brazil, performed exclusively in the privacy of doctors' offices and only when authorized by the Ministry of Health for research purposes. Additionally, the regulations break down a class barrier. With the manufacture and use of IUDs made fully legal and costs lowered, the IUD is no longer available only to middle and uppper class women. Now the IUD may be used by the poorest groups of women in the population. Only 1 type of IUD is authorized the copper IUD with plastic stem and copper parts. It was chosen because it releases substances that kill the sperm as soon as they enter the uterus and is therefore not an abortifacient. Another reason was its effectiveness; the probability of pregnancy with copper IUDs is about 2%. Problems associated with IUD use include bleeding during menstruation, pelvic infections, vaginitis, and cramping. Perforation of the uterus can occur when the device is not inserted correctly. In the case of the copper IUD, problems occur in only 3-7% of users and usually are remedied by removal of the device. Companies interested in manufacturing IUDs must submit their product for approval by the ministry.^ieng

Attitudes toward family planning.

PIP: Many of the 135 countries participating in the 1974 UN World Population Conference were far from accepting the basic human right to decide freely and responsibly the number and spacing of their children and to have the information, education, and means to do so. Considerable progress has been made since then, and the number of developing countries that provide direct government support for family planning has increased to over 60%. Many have liberalized laws and regulations which restricted access to modern contraceptive methods, and a growing number provide family planning services within their health care programs. A few have recognized the practice of family planning as a constitutional right. In late 1983 at the Second African Population Conference, recognition of family as a human right was strongly contested by several governments, particularly those of West Africa. in developed countries most of the women at risk of unwanted pregnancy are using contraceptives. Of the major developing regions the highest use level is in Latin America, wherein most countries 1/3 to 1/2 of married women are users. Levels in Asian countries range from up to 10% in Afghanistan, Nepal, and Pakistan to up to 40% in the southeastern countries. China, a special case, now probably exceeds an overall use level of 2/3 of married women. Contraceptive use is lowest in Africa. There is room for improvement even among many of the successful family planning programs, as access to contraceptives usually is not sufficient to overcome limiting factors. To ensure the individual's free choice and strengthen the acceptability and practice of family planning, all available methods should be provided in service programs and inluded in information and education activities. Family planning programs should engage local community groups, including voluntary organizations, in all aspects of planning, management, and allocation of resources. At the government level a clear political commitment to family planning and population policies is essential as is administrative support. All government agencies concerned with socioeconomic benefit to the family and the community need to be involved in the coordinated planning and implementation.^ieng