Contraception provision in the postpartum period: Knowledge,views and practices of midwives

BackgroundWomen are susceptible to unintended pregnancies in the first year after giving birth, particularly as consideration of contraception may be a low priority during this time. Discussing and providing contraception before women leave hospital after giving birth may prevent rapid repeat pregnancy and its associated risks. Midwives are well placed to assist with contraceptive decision-making and provision; however, this is not routinely undertaken by midwives in the Australian hospital setting and little is known regarding their views and experiences in relation to contraception.MethodsAn anonymous survey was conducted with midwives at two urban hospitals in New South Wales to better understand their contraceptive knowledge, views and practices regarding midwifery-led contraception provision in the postpartum period.FindingsThe survey was completed by 128 midwives. Most agreed that information about contraception provided in the postpartum period is valuable to women, although their knowledge about different methods was variable. The majority (88%) believed that midwives have a role in providing contraceptive information, and 79% reported currently providing contraceptive counselling. However, only 14% had received formal training in this area.ConclusionFindings demonstrate that most midwives provide some contraception information and believe this is an important part of a midwife’s role. Yet most have not undertaken formal training in contraception. Additional research is needed to explore the content and quality of midwives’ contraception discussions with women. Training midwives in contraceptive counselling would ensure women receive accurate information about available options. Upskilling midwives in contraception provision may increase postpartum uptake and reduce rapid repeat pregnancies.     

Workshop on long-term contraceptives

The National Population Council Secretariat (NPCS) of Ghana held a three-day workshop on long-term contraceptives in 1996 in collaboration with the Ministry of Health, the Association of Voluntary Surgical Contraception, and the Johns Hopkins Population Communication Services. The session was funded by USAID. The executive director of NPCS, Dr. Richard Turkson, said that the slow rate of contraceptive acceptance was an obstacle to population control despite political concern that rapid population growth exerted an adverse impact on the economy. Only 10% of married women were using long-term or permanent methods of contraception. The hope was voiced that the participants would devise practical and cost-effective education, information, and communication (IEC) strategies to boost the demand for long-term contraceptive methods among sexually active people in Ghana. It was essential that these strategies and activities were based on a realist assessment of the demographic and social situation of the country. The examination of case studies in cultures similar to Ghana would also offer valuable lessons. The factors that hinder the acceptance of long-term methods include misconceptions, myths, and false rumors rooted in a general lack of knowledge among the people. Participants were urged to come up with strategies to counter these problems, and service providers were encouraged to improve their knowledge about contraceptive methods and counseling skills. Male involvement in contraception was also advocated. Statistics show that most Ghanians practicing contraception were using short-term methods such as foaming tablets, pills, and condoms. However, it is necessary to shift to long-term methods such as injectables, implants, and sterilization in order to achieve significant reductions in fertility.     

Barriers to contraceptive use among Pakistani couples

Despite the existence of a family planning program in Pakistan since 1965 and widespread knowledge among Pakistanis about contraception, there is a high level of unmet need for family planning. One recent survey found that while 53% of married women express the desire to avoid pregnancy, less than 20% use contraception. A recent Population Council study conducted in urban and rural areas of Punjab province investigated personal beliefs, family circumstances, social norms, and gender relations among 1310 married women and 554 of their husbands. The unmet need for contraception was highest among women over age 30 years, those with more living children, less educated women, and women living in rural areas. The study found that while most Pakistanis approve of family planning, obstacles to contraceptive use exist in most marriages. 97% of respondents who wanted another child wished for a boy. That preference for sons influences contraceptive use behavior. The fear of social disapproval of contraceptive use, perceived opposition from in-laws and husbands, and fear of health side effects and divine punishment were major reasons identified against contraceptive use. Female contraceptive users were more autonomous and likely to make domestic decisions without consulting their husbands, while husbands defer to social and cultural norms.     

Secrecy and silence: why women hide contraceptive use

A recent Population Council survey of 1860 married women and 1056 of their husbands in urban Zambia found that many women who use contraception do so without their husbands' knowledge and that those women who hid their practice of contraception from their husbands did so because they found it very difficult to bring up the subject of family planning with them. These findings indicate that low levels of contraceptive use are not the result of a simple communication matter. Sex and sexuality are often the exclusive domain of African husbands. As such, if a wife initiates a discussion of family planning, she may threaten her husband's sense of control and create discord within the family. The culture of silence about sex and sexuality is very strong in Africa. 57% of women stated that were they to propose contraceptive use with their husbands and the husband opposed such practice, they would nonetheless use them without his knowledge. 7% of the women stated that if their husbands disapproved of contraceptive use, they would nonetheless openly use a method against his wishes. The majority of women correctly perceived their husbands' views on family planning use and fertility preferences. In focus groups, both men and women said that they did not believe that women have the right to independently act upon their reproductive preferences. A husband's inadequate financial support of his children could, however, justify clandestine contraceptive use. These findings point to the need to include easily hidden methods in the mix of contraceptives family planning programs offer. Moreover, service providers should not automatically encourage husbands' involvement. A client's right to privacy should always be respected.     

Why women who don't want to get pregnant don't use contraception

In the developing world about 120 million women have an unmet need for contraception. They want to postpone childbearing, yet they do not use contraception, often because of the unavailability of services and supplies. However, according to a recent article by John Bongaarts, the primary factors are lack of knowledge about a contraceptive method, concern about side effects, and the disapproval of the male partner in developing countries. Lack of knowledge means inability to describe the uses of a contraceptive, its side effects, and the locale of its availability. An approximate knowledge index was calculated for such women, which showed that knowledge level positively correlated with contraceptive prevalence. Countries where the index was below 50% had a contraceptive prevalence of 8% only. The determinant reasons why women were reluctant to use the pill, IUD, and sterilization had to do with health and the fear of side effects, such as nausea and increased bleeding. The contraceptive prevalence among these women was reduced by 71% for the pill, 86% for the IUD, and 52% for sterilization. In Sub-Saharan countries nearly 70% of women cited partner disapproval of contraception, although they had never discussed family planning with their partners. The central concept for reducing unmet need is access with quality, which means that services are voluntary, safe, and appropriate in delivery. Some of the recommendations to reduce the unmet need for contraception include: one-on-one same-sex discussions to increase contraceptive knowledge and acceptability; sensitive responses by programs to their client's health concerns; support by service providers to women negotiating with male partners in order to mitigate male disapproval; and sex education and family planning services to reduce unwanted and early sexual contact and pregnancy while girls develop identities apart from mothering roles.     

Contraceptive rings provide simple protection

The Population Council is currently conducting 4 clinical trials of the vaginal contraceptive ring. This device remains in the vagina for weeks or months, releasing hormone formulations tailored for a variety of contraceptive needs. Rings that deliver both estrogen and progesterone can be kept in place for 3 weeks, then removed for the last week of the cycle. Since the steroids diffuse directly from vaginal tissues to the bloodstream, smaller steroid doses can be used than for oral contraceptives (OCs). In contrast to IUDs, which require insertion and removal by medical providers, women can be taught to insert and remove the flexible device themselves. One of the rings being evaluated by the Population Council is suitable for breast feeding women. It does not contain estrogen and appears to have no adverse effect on either lactation or infant growth. Preliminary findings have confirmed the effectiveness of a ring that remains in place 6-12 months. Advantageous for distribution in developing countries would be a contraceptive ring that lasts for 12 months and could be priced competitively with OCs. In addition to contraception, the ring can be used by postmenopausal women for hormone replacement treatment.     

Progress in male contraceptive research

80% of the world's contraceptive users are women. This gender-based usage has occurred due to the emphasis of family planning programs and contraception research on female methods. Even if men desired to take responsibility for contraception, only the condom and vasectomy are available and have a reasonable assurance of protection. The Population Council has been researching male contraception through its Center for Biomedical Research. An oral contraceptive derived from gossypol, a cottonseed plant pigment, is being tested after successful clinical trials were performed in China during the 1970s. Also being investigated are male hormonal methods that regulate sperm production while protecting against loss of potency, loss of libido, and changes in secondary sex characteristics. A hormonal implant, effective for one year, has been in Phase I clinical trials since 1993. A small Phase I clinical trial is in process for a vaccine/implant for men that is effective for one year. Testing with injectables for men has suggested that different hormonal mixes could increase cardiovascular risk for men and exacerbate prostate cancer. Research has focused on new materials for condoms. Kraton-type materials are made from block copolymers and polyurethanes, and these condoms have shown some promise. The advantages of these products are that they are allergen-free, less susceptible to oxidation, and can be of thinner construction, which would increase sensitivity and acceptability. The percutaneous chemical method of no-scalpel vasectomy has been studied as a means of blocking passage of sperm in the vas deferens. In China and India, injections with liquid silicone, polyurethane, neem-oil, and n-butyl-cyanoacrylate mixed with phenol are being studied. Zinc injections that cause the epididymis to atrophy are being tested on animals in the US. Lasers and fiber cautery are other methods under investigation. Increased funding is essential for these and other research efforts.     

Expanding contraceptive choice: findings from Zambia

The Population Council's Expanding Contraceptive Choice program works to increase the contraceptive options available to women and men in developing countries. To achieve this goal, the Council is pursuing a new approach, one which begins with an assessment of contraceptive needs from which recommendations for upgrading contraceptive services are based. This new approach was tested in four countries including Zambia in which Stage I--contraceptive needs assessment--was completed. Results of the assessment indicated that despite the efforts of the national family planning program, 33% of Zambian women who do not want to get pregnant do not practice contraception. Only 9% of women use a modern contraceptive method. These results suggest that there is a need for introducing new contraceptive technologies and for expanding utilization of existing methods in the country. Also, stage I assessment yielded other positive outcomes which are enumerated in this paper. In response to this report, the Zambian government decided to proceed with stage II research on the viability of introducing new and underutilized contraceptive methods into the national family planning program.     

Adding choice to the contraceptive mix: lessons from Indonesia

Researchers asked 1945 women of reproductive age living in East Java, Indonesia what contraceptive method they preferred during the women's 1st visit to a government family planning clinic. Soon after field workers introduced them to a method, the researchers asked the women what method the field workers suggested and what method the women planned to use. They again spoke to them 1 year later to determine contraception continuation. The field workers granted 86.3% of the women their method choice. Only 9% of these women had stopped using their chosen method while 72% of the women who were not allowed to use their chosen method stopped using the method assigned to them. Thus choice was a key factor in sustained use of contraceptives. Further if family planning workers stick to a mutual participation of both themselves and their clients, they respect clients' method choices and, by informing clients about the chosen method, they strengthen clients' decision making. In the early 1990s, another researcher had developed a system to determine contraceptive needs at various stages of the reproductive period (before 1st marriage, after 1st marriage but prior to 1st birth, after 1st birth but prior to last birth, and after last birth). She applied observed contraceptive preferences for women using contraception within each life cycle stage to the age specific contraception need, derived from data from the 1987 Contraceptive Prevalence Survey for Indonesia, to determine the ideal contraceptive mix. Her calculations demonstrated that oral contraceptive use was high, IUD use was low, particularly among older women, and too few sterilizations had occurred, particularly among older women. Thus Indonesia needed to broaden the contraceptive mix to encourage methods that better meet women's reproductive life cycle needs.     

Reducing unsafe abortion in Kenya

In Kenya, where abortion is permitted only to save a woman's life, unsafe abortion accounts for over one-third of maternal deaths and hospital emergency rooms are overcrowded with women suffering complications of induced and spontaneous abortions. Postabortion care, a service linking emergency treatment of abortion complications with family planning counseling and comprehensive reproductive health care, is under review by the Population Council as a method of reducing maternal mortality and morbidity as well as the incidence of repeat unsafe abortion. An operations research study conducted by the Kenyan Ministry of Health identified several obstacles to such care: lack of information on abortion management, limited service provider skills, inconsistent supplies, and a lack of empathy for women presenting with incomplete abortion. Although 86% of abortion patients from 6 Kenyan hospitals expressed an interest in contraceptive counseling, only 5% reported actually receiving such information. As part of the operations research, these 6 hospitals introduced postabortion care, including, in 3 hospitals, use of manual vacuum aspiration. All 6 hospitals provided contraceptive counseling and psychosocial support. Based on the success of this experience, the Ministry of Health is considering introducing postabortion care to all hospitals in Kenya.     

On the Modernity of Traditional Contraception: Time and the Social Context of Fertility

Many studies of fertility implicitly equate temporal management, biomedical contraception, and “modernity” on the one hand, and “tradition,” the lack of intentional timing, and uncontrolled fertility on the other. This article questions that equation, focusing on the widespread use of periodic abstinence in southern Cameroon. Drawing on field data and the Cameroon Demographic and Health Survey, the article investigates how local concepts of timing shape both contraceptive choice and the evaluation of methods as “modern” or “traditional.” Cameroonian women prefer periodic abstinence because they perceive it as “modern,” a modernity tied both to the social context in which it is taught and to its unique temporal form. By contrast, Depo‐Provera, pills, and the IUD are seen as less‐than‐modern, because they are less exigent of temporal control. The reliance on a behavioral, rather than technological, contraceptive method parallels the experience of the European fertility transition. Cameroonian women draw on a complex social repertoire in making contraceptive choices; methods are preferred or rejected not only on the basis of their efficacy in averting pregnancy, but also because of their correspondence to models of legitimate social action. Reproductive practices may have social motivations that are unrelated to fertility per se.     

Application of life table techniques to measurement of contraceptive effectiveness

Two problems are associated with the analysis of use-effectiveness of contraception. First, couples belonging to a sample of contraceptors typically vary in their monthly chances of contraceptive failure. Second, one does not observe for many, and perhaps a majority of the couples, how long they can remain protected with the contraceptive, because either they are stopping contraception to plan a pregnancy or else observation of them is being interrrupted by lost contact, by discontinuation of contraception for other reasons, or by the end of the study. It is argued that because of these two problems-namely, sample heterogeneity and incomplete histories-the Pearl pregnancy rate, which has been traditionally used to measure contraceptive effectiveness, is inadequate.A life table method is described that permits one to combine incomplete histories with complete ones for purposes of estimating the proportions of the sample that might have remained protected for specified periods if all members had remained under observation for these periods. The versatility of the techniques is illustrated in relation toa retrospective survey. A detailed account of procedure is given. Finally, it is shown that only under specialized conditions that are rarely met in practice is it possible to estimate the results of the new technique from knowledge of Pearl pregnancy rates alone.     

Contraceptive Initiation Patterns in Thailand

Data from the Thailand Demographic and Health Survey permit a detailed examination of the pattern of contraceptive initiation in terms both of first post-marital contraceptive use and initiation of use following childbirth. A clear trend towards beginning contraception earlier in the family-building process over the course of the fertility transition is evident. During the earliest stage, contraception was first used mainly after a couple had already achieved their desired family size, but later on couples increasingly began use in order to space births, and most recently it has become common to begin use to delay the start of childbearing. There are two distinctive patterns of contraceptive initiation following childbirth. For women who chose sterilization, initiation occurs during the immediate post partum period, while for those who used other methods, use most commonly began shortly after the return of menses. As a result, few Thai women are at present unprotected against unplanned pregnancies for any substantial period of risk following childbirth. Beginning to use contraception early in the family-building process and rapid adoption of contraception following childbirth are now found in most segments of Thai society, testifying to the maturing of Tailand's fertility transition.     

An update on the pill

The discussion traces the development of the oral contraceptive (OC) pill and presents the most recent medical findings on OC and its effects. In 1959 the 1st combined OC, Enovid, was officially approved for use in the US after clinical trials in Los Angeles and Puerto Rico. By 1975, OCs were being used in the US by more than 1/3 of married women who practiced family planning and by an even higher percentage of unmarried contraceptive users. Retail pharmacy sales of OCs have declined by 40% during the 1975-79 period. The major reason given for the decline was the side effects or fear of side effects arising from OC use. Many OCs are available today because of an increasing variety of chemical combinations and the rapid increase in product names, according to "Oral Contraceptives: A Guide for Programs and Clinics," a Pathfinder Fund handbook. The authors classified OCs into 2 general groups -- combined pills and the mini-pills. OCs used in the combined preparation each contain 2 synthetic hormones -- estrogen and progestin. The combined OC is 99% effective when taken properly. The most popular belief now is that OCs act by interfering with the normal menstrual cycle. The mini-pills, which contain small doses of synthetic progestins, have a contraceptive effect by altering the cervical mucus and by altering the lining of the womb or endometrium. Absolute, strong relative, and other relative contraindications to pill use are listed. Side effects that are possibly life threatening include blood clots in the legs, pelvis (lower abdomen), lungs, heart, or brain. Women OC users over 40 have a higher risk of heart attack than younger users, and users over 40 who smoke have the highest risk of heart attack. Benign tumors of the liver, which have been found to be more common in women who use OCs, may cause rupture of the capsule of the liver, extensive bleeding, and even death. Rare tumors of the liver, hepatocelluar adenomas, are more likely to occur in long term OC users, older women, and women using high dose pills. Side effects considered serious are gallbladder disease and hypertension. Fairly minor OC side effects are listed as are noncontraceptive benefits of OC use.     

Problems of abortion in Britain - Aberdeen, a case study

Summary This paper reports on nearly all pregnancies occurring in the City of Aberdeen in the years 1961-74 (births, and therapeutic and spontaneous abortions) and on male and female sterilization and the use of contraception. The collection of these data for a defined community was made possible through the coordinated and comprehensive maternity and contraceptive services. Several important innovations made during the years included the introduction of oral contraception and the inter-uterine device, laparoscopic sterilization and vasectomy. The Abortion Act 1969 came into force and at different times the Local Authority Family Planning Clinic made many changes including the removal of charges and of the need for referral. The pattern of outcome differs for legitimate and illegitimate pregnancies, which are considered separately. Over half of all first pregnancies now occur before marriage and their outcome in women in different occupational groups is discussed. Oral contraception is favoured for postponing or spacing pregnancies, but when it comes to limitation of family size, couples have increasingly requested sterilization. Nevertheless there has been a ten-fold increase in the proportion of pregnancies being terminated. Aberdeen's birth rate is now below replacement level but the real objective 'every pregnancy a wanted pregnancy' is far from being achieved in either married or unmarried women.     

Contraceptive use at first intercourse among Jewish women in Israel, 1962–1988

Using data from the 1987–1988 Study of Fertility and Family Formation,this study examines the family planning practices of Jewish Israeli womenwho first had intercourse between 1962 and 1988. The overwhelming majorityof women reported using no contraception at first intercourse, and among those who did practice birth control approximately half relied on modern techniques. While the likelihood that Israeli women used contraception at first sex changed little between 1962 and 1988, there has been a marked shift towards the adoption of efficient methods of birth control. Moreover, factors which promote female empowerment, including education and military service, have been positively associated with contraceptive use at first intercourse. Among those women who practiced contraception at first intercourse, those from Africa and Asia have been especially likely to make use of inefficient methods such as withdrawal.     

Effects of education on reproductive behavior: lessons from Pakistan

Evidence from the Pakistan Demographic and Health Survey 1990/91 (PDHS) and a 1987 study by Zeba A. Sathar and Karen Oppenheim on women's fertility in Karachi and the impact of educational status, corroborates the correlation between improved education for women and fertility decline. PDHS revealed that current fertility is 5.4 children/ever married woman by the end of the reproductive period. 12% currently use a contraceptive method compared to 49% in India, 40% in Bangladesh, and 62% in Sri Lanka. The social environment of high illiteracy, low educational attainment, poverty, high infant and child and maternal mortality, son preference, and low status of women leads to high fertility. Fertility rates vary by educational status; i.e., women with no formal education have 2 more children than women with at least some secondary education. Education also affects infant and child mortality and morbidity. Literacy is 31% for women and 43% for men. 30% of all males and 20% of all females have attended primary school. Although most women know at least 1 contraceptive method, it is the urban educated woman who is twice as likely to know a source of supply and 5 times more likely to be a user. The Karachi study found that lower fertility among better educated urban women is an unintended consequence of women's schooling and deliberate effort to limit the number of children they have. Education-related fertility differentials could not be explained by the length of time women are at risk of becoming pregnant (late marriage age). Fertility limitation may be motivated by the predominant involvement in the formal work force and higher income. The policy implications are the increasing female schooling is a good investment in lowering fertility; broader improvements also need to be made in economic opportunities for women, particularly in the formal sector. Other needs are for increasing availability and accessibility of contraceptive and family planning services and increasing availability and accessibility of contraceptive and family planning services and increasing knowledge of contraception. The investment will impact development and demography and is an adjunct to child health an survival.     

Risk-taking and contraceptive behavior among unmarried college students

The contraceptive behavior of sexually active, never-married college women was examined using multiple regression analyses. Use of an effective method of contraception was highly situation-specific: length of relationship and frequency of intercourse were the variables most highly correlated with use of effective contraception, followed by method of contraception used at first coitus and knowledge of reproduction. Failure to use effective contraception was not associated with low estimates of pregnancy risk, nor with high utility of pregnancy, nor with uniquely high willingness to seek abortion. The results of the present study suggest that use or non-use of effective contraception is mediated by the predictability of sexual intercourse.We would like to thank Ira H. Bernstein for his assistance with computer programming and data analysis. Reprints are available from Ms. Irene Steeger, Center for Population and Family Health, Columbia Unviersity, New York.     

The accessibility of contraceptives and service quality in drug stores in Shanghai

This news brief reports findings from a 1996 survey of contraceptive accessibility and service quality in Shanghai, China. Surveys were administered among 100 attendants from 58 drug stores in 5 districts and counties in Shanghai. Drug stores are a primary source of supply of contraception. Findings indicate that 80% of respondents in Nanshi, 85% in Putuo, 45% in Baoshan, 80% in Qingpu, and 70% in Fengxian were satisfied with drug stores as a source of supply of contraception. The mean score on knowledge of contraception among attendants was 68.4; the range was 85.5-27.6. The mean score of ever trained attendants was higher (72.4), compared to 65.8 among untrained attendants. 80% of attendants served customers with consideration and answered questions willingly. Attendants were not able to provide adequate answers to some questions about contraceptives due to deficits in their own knowledge relative to contraception.