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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.


Approaches to Contraceptive Methods for Men  

Christina Wang and Ronald S. Swerdloff

Unlike female contraception methods, male contraception has had no new approved approaches since the introduction of no-scalpel vasectomy over 40 years ago. Men who wish to share family planning responsibilities have withdrawal or condoms as available reversible methods of contraception. These methods have a high failure rate and are user dependent. While a vasectomy can be surgically reversed, it should be considered a form of permanent contraception because pregnancy in the partner cannot be guaranteed after reversal. Experimental methods, including chemicals to block the vas deferens, are undergoing testing. Since the 1970s, hormonal male contraception using testosterone alone and testosterone combined with a progestin demonstrated high efficacy and few short-term adverse effects. Long-term adverse effects cannot be determined until a hormonal male contraceptive method is approved, allowing safety studies to be performed. Contraceptive efficacy studies have shown failure rates comparable to those of hormonal female contraception. Current studies focus on user-controlled methods such as daily transdermal gels, oral pills, and long-acting injectables. Large-scale population studies performed in the early 2000s confirmed that over 50% of men surveyed would try a new male contraceptive, preferring an oral pill over injections or implants. These surveys also showed that over 80% of the women welcomed a new method of contraception, and over 90% of them would trust their partner to use the male method consistently. With changes in gender roles and gender equity in relationships, it is anticipated that male participation in family planning methods will be enhanced. Successful efficacy, safety, and reversibility with hormonal male-directed methods may pave the way new, targeted nonhormonal approaches. Once the testicular target is selected, new compounds can be identified based on structure function analyses or high-throughput screening to identify agonists or antagonists of the target.


Adolescent Sexual and Reproductive Health  

Ndola Prata and Karen Weidert

Adolescence, spanning 10 to 19 years of age, begins with biological changes while transitioning from a social status of a child to an adult. For millions of adolescents in low- and middle-income countries (LMICs), this is a period of exposure to vulnerabilities and risks related to sexual and reproductive health (SRH), compounded by challenges in having their SHR needs met. Globally, adolescent sexual and reproductive ill-health disease burden is concentrated in LMICs, with sexually transmitted infections and complications from pregnancy and childbirth accounting for the majority of the burden. Adolescents around the world are using their voices to champion access to high-quality, comprehensive SRH information and services. Thus, it is imperative that adolescents’ SRH and rights be reinforced and that investments in services be prioritized.


First Trimester Medication Abortion: Public Health Challenges and Clinical Guidance  

Devanshi Somaiya and Candace Lew

According to 2015–2019 data, there are 121 million unintended pregnancies each year globally. One hundred eleven million of these occur in low- and middle-income countries. Of all unintended pregnancies, 61%, or about 73 million pregnancies, end in abortions annually, at the rate of 39 abortions per 1,000 women of reproductive age. About half the abortions, or 35 million of them, are unsafe, contributing to the 299,000 maternal deaths each year. These, in turn, have implications for the realization of almost every one of the 17 United Nations Sustainable Development Goals, specifically ensuring good health and well-being, achieving gender equity, and ending poverty. Abortions occur in every country irrespective of income level or the legal status of abortion. From 1990 to 2019, there has been a greater increase in the proportion of pregnancies ending in abortions in countries where abortion is restricted compared with countries where abortion is broadly legal. A growing proportion of these abortions are medication abortions, incorporating the use of mifepristone or misoprostol or both. The availability of this becomes even more important in areas where policy or infrastructure or both are more restrictive for providing safe, legal abortions. Providing quality, women-centered, comprehensive abortion care that is equitably accessible hence becomes imperative to addressing a woman’s ability to access appropriate medical care for her reproductive needs. Making this amenable to a digital platform overcomes even more barriers, be they socioeconomic or policy-driven. Fortunately, recent research and evidence support this, hence broadening the availability of safe abortion care into areas and demographics that remained precluded from the availability of comprehensive reproductive health care. Targeted progress and strengthened commitments are needed to further this penetration and provide access to compassionate, safe, and quality care for abortion and family planning.


Sexual and Reproductive Health in China  

Qianling Zhou, Chu-Yao Jin, and Hai-Jun Wang

Databases of PubMed, Scopus, and China National Knowledge Infrastructure (CNKI) were used to search relevant articles on sexual and reproductive health (SRH) in China published from 2005 to the present (2021), based on the World Health Organization’s (WHO) Operational Framework on Sexual Health and Its Linkages to Reproductive Health. The following results were found. (a) SRH education and information among the Chinese were insufficient, in particular regarding contraception, pregnancy, and sexually transmitted diseases (STDs). Adolescents, migrants, and the rural population had insufficient knowledge of SRH. (b) Fertility care services were mainly available in large cities, in urban areas, and for married couples. Services targeted for rural-to-urban migrants, rural residents, and the disabled and elderly are needed. (c) A total of 22.4% of youths aged 15–24 had premarital sexual intercourse, and the age of first sexual intercourse was decreasing. Risky sexual behaviors included multiple partners, casual and commercial sex, and having sex after drinking alcohol. (d) The contraceptive practice rate of women aged 15–49 in China was higher than the world’s corresponding figure. However, contraceptive use among young people was low (only 32.3% among unmarried women). (e) Unmarried pregnancy induced by low contraceptive practice is a critical issue in China. (f) Induced abortion was the major consequence of unmarried pregnancy. The rate of induced abortion among the general population in 2016 was 28.13‰, and the rate among unmarried women was increasing annually. (g) There were 958,000 HIV-infected cases in China as of October 2019. Sexual transmission was the major transmission route of HIV-AIDS. More men than women were infected. Men having sex with men comprised the high-risk group of sexual transmission of HIV-AIDS. (h) Gender-based violence including intimate partner violence (IPV), sexual violence, sexual coercion, and child sexual abuse (CSA) might be underreported in China, since many victims were afraid to seek help as well as due to limited services. Legal and regulatory measures should therefore be taken to prevent and reduce gender-based violence. For future perspectives of SRH in China, it is important to pay attention to SRH education and services. An up-to-date national survey on SRH is needed to reflect the current situation and to capture changes over the past decade. Most of the current research has been conducted among adolescents, and more studies are needed among other groups, such as the disabled, the elderly, and homosexual populations.


Gender and Reproductive Health Empowerment  

Shannon N. Wood, Robel Yirgu, and Celia Karp

Gender and reproductive health empowerment are central concepts for understanding and improving population health and well-being. Beginning in the 1990s, global platforms, including the United Nations, began recognizing gender-based inequities, including violence against women and lack of women’s participation in education and the economy, as social determinants of health. Since the 1990s there has been growing international interest in the concept of empowerment as a means for understanding the mechanisms that drive outcomes related to health and development. Although several definitions of empowerment have evolved over the past 30 years, the pivotal work of Dr. Naila Kabeer has grounded many interpretations of women’s empowerment as a process by which a woman has the individual capacity and freedom to act on her own choices in life. To date, the lack of comparable empowerment definitions remains a major hindrance to conducting comprehensive research that links empowerment to health outcomes. Additionally, while most recognize empowerment as a multidimensional process, the majority of measures used for examining this concept have been unidimensional (focused on agency, self-efficacy, household decision-making, etc.), thereby limiting the understanding of empowerment across populations, geographies, and contexts. Subsequent framing of women’s empowerment has focused specifically on sexual and reproductive empowerment, recognizing that women may be empowered in certain realms (e.g., economic), but not in others (e.g., autonomy in contraceptive decisions). Developments in the conceptualization of reproductive empowerment since 2015 have paved the way for improved measurement and exploration of this concept, yet gaps in research remain.


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.


Operationalizing Human Rights in Sexual and Reproductive Health and Rights Programming: An Example from a Global Family Planning Partnership  

Karen Hardee

The International Conference on Population and Development (ICPD), which has guided programming on sexual reproductive health and rights (SRHR) for 25 years, reinforced that governments have a role to play in addressing population issues but in ways that respect human rights and address social and gender inequities. The shift at ICPD was partly in response to excesses that had occurred in some family planning programs, resulting in human rights abuses. The 2012 London Summit on Family Planning refocused attention on family planning as a crucial component of SRHR and, in part due to significant pushback on the announcement of a goal of reaching an additional 120 million women and girls with contraception by 2020 in the world’s poorest countries, ignited work to ensure that programming to achieve this ambitious goal would be grounded in respecting, protecting, and fulfilling human rights. This attention to human rights has been maintained in Family Planning 2030 (FP2030), the follow on to Family Planning 2020 (FP2020). While challenges remain, particularly in light of pushback on reproductive rights, widespread work over the past decade to identify human rights principles and standards related to family planning, integrate them into programming, strengthen accountability, and incorporate rights into monitoring and evaluation has improved family planning programs.


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.


Sexual and Reproductive Health in India  

Shireen Jejeebhoy, K. G. Santhya, and A. J. Francis Zavier

India has demonstrated its commitment to improving the sexual and reproductive health of its population. Its policy and program environment has shifted from a narrow focus on family planning to a broader orientation that stresses sexual and reproductive health and the exercise of rights. Significant strides have been made. The total fertility rate is 2.2 (2015–2016) and has reached replacement level in 18 of its 29 states. The age structure places the country in the advantageous position of being able to reap the demographic dividend. Maternal, neonatal, and perinatal mortality have declined, child marriage has declined steeply, contraceptive use and skilled attendance at delivery have increased, and HIV prevalence estimates suggest that the situation is not as dire as assumed earlier. Yet there is a long way to go. Notwithstanding impressive improvements, pregnancy-related outcomes, both in terms of maternal and neonatal mortality and morbidity, remain unacceptably high. Postpartum care eludes many women. Contraceptive practice patterns reflect a continued focus on female sterilization, limited use of male methods, limited use of non-terminal methods, and persisting unmet need. The overwhelming majority of abortions take place outside of legally sanctioned provider and facility structures. Over one-quarter of young women continues to marry in childhood. Comprehensive sexuality education reaches few adolescents, and in general, sexual and reproductive health promoting information needs are poorly met. Access to and quality of services, as well as the exercise of informed choice are far from optimal. Inequities are widespread, and certain geographies, as well as the poor, the rural, the young, and the socially excluded are notably disadvantaged. Moving forward and, in particular, achieving national goals and SDGs 3 and 5 require multi-pronged efforts to accelerate the pace of change in all of these dimensions of health and rights.