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Experimental and Intervention Studies of Couples and Family Planning in Low- and Middle-Income Countries: A Systematic Review  

Stan Becker and Dana Sarnak

The vast majority of births in the world occur within marriages or stable partnerships. Yet family planning programs have largely ignored the male partner. One justification for this nearly exclusive focus on women has been that almost all of the modern contraceptive methods are female-oriented. In contrast, studies of fertility preferences within couples that included a later follow-up have shown that men’s fertility preferences are important for predicting subsequent births. Interspousal communication can be key to resolving differences in desired family size and for promoting open contraceptive use. Experimental studies with couples on family planning education and/or counseling show higher contraceptive prevalence or continuation in the couples groups than in the women-only groups, though the differences are not always significant statistically. Other intervention studies have varying designs and mixed results. The purpose of this systematic review is to summarize the research findings on interventions with couples on reproductive health from experimental and pre–post observational studies. An important conclusion is that couples education and counseling are critical components for involving male partners. There is a need for systematic research on couples using a standardized intervention and fixed follow-up times and including analyses of cost-effectiveness.


Contraceptive Technology  

Timothee Fruhauf and Holly A. Rankin

Contraceptive technology refers to tools that are used to delay or prevent pregnancy. Modern contraceptive technology encompasses female or male sterilization, intrauterine devices, contraceptive implants, contraceptive pills, contraceptive patches, intravaginal rings, diaphragms, external or internal condoms, emergency contraception, and certain fertility awareness–based methods. Duration of these methods’ effects varies from permanent and irreversible to long-lasting and reversible to short term with day-to-day reversibility. The efficacy of modern contraceptive technologies at preventing pregnancy ranges between 76% and 99.95% during the first year of typical use. Mechanisms of action vary from physically impeding meeting of sperm and oocyte to use of exogenous reproductive hormones to alter fertility. Contraceptive counseling for the selection of a method should adopt a shared decision-making framework and can consider advantages, disadvantages, contraindications, and side effects of a method to align with a patient’s contraceptive use goals. Certain clinical contexts, such as post-abortion, postpartum, adolescent patients, and patients with elevated body mass index have contraceptive nuances that are important to consider. Finally, contraceptive technology has many non-contraceptive benefits that provide additional indications for their use.


Demographic Transition in India: Insights Into Population Growth, Composition, and Its Major Drivers  

Usha Ram and Faujdar Ram

Globally, countries have followed demographic transition theory and transitioned from high levels of fertility and mortality to lower levels. These changes have resulted in the improved health and well-being of people in the form of extended longevity and considerable improvements in survival at all ages, specifically among children and through lower fertility, which empowers women. India, the second most populous country after China, covers 2.4% of the global surface area and holds 18% of the world’s population. The United Nations 2019 medium variant population estimates revealed that India would surpass China in the year 2030 and would maintain the first rank after 2030. The population of India would peak at 1.65 billion in 2061 and would begin to decline thereafter and reach 1.44 billion in the year 2100. Thus, India’s experience will pose significant challenges for the global community, which has expressed its concern about India’s rising population size and persistent higher fertility and mortality levels. India is a country of wide socioeconomic and demographic diversity across its states. The four large states of Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan accounted for 37% of the country’s total population in 2011 and continue to exhibit above replacement fertility (that is, the total fertility rate, TFR, of greater than 2.1 children per woman) and higher mortality levels and thus have great potential for future population growth. For example, nationally, the life expectancy at birth in India is below 70 years (lagging by more than 3 years when compared to the world average), but the states of Uttar Pradesh and Rajasthan have an average life expectancy of around 65–66 years. The spatial distribution of India’s population would have a more significant influence on its future political and economic scenario. The population growth rate in Kerala may turn negative around 2036, in Andhra Pradesh (including the newly created state of Telangana) around 2041, and in Karnataka and Tamil Nadu around 2046. Conversely, Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan would have 764 million people in 2061 (45% of the national total) by the time India’s population reaches around 1.65 billion. Nationally, the total fertility rate declined from about 6.5 in early 1960 to 2.3 children per woman in 2016, a result of the massive efforts to improve comprehensive maternal and child health programs and nationwide implementation of the national health mission with a greater focus on social determinants of health. However, childhood mortality rates continue to be unacceptably high in Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh (for every 1,000 live births, 43 to 55 children die in these states before celebrating their 5th birthday). Intertwined programmatic interventions that focus on female education and child survival are essential to yield desired fertility and mortality in several states that have experienced higher levels. These changes would be crucial for India to stabilize its population before reaching 1.65 billion. India’s demographic journey through the path of the classical demographic transition suggests that India is very close to achieving replacement fertility.