Comprehensive services at Fabella Center

The Jose Fabella Memorial Hospital Comprehensive Family Planning Center was the 1st family planning center to conduct minilaparotomy in the Philippines. It was also the 1st center to conduct research on family planning and to offer training in family planning to nurses, doctors, midwives, and medical students. The center is funded by the Philippine government with about 85% of hospital funds going to salaries of the staff. Supplementing the funding are medicine, equipment, and subsidies for sterilization given by the Commission on Population (Popcom). Research on chemical sterilization requires patients to take oral contraception (OC) or use the condom while under observation for about 4 months. In the case of female patients, this means until the fallopian tubes have been blocked due to the injection of an opaque solution. The patients are then checked for effects on health, sexual practices, and the regularity of menstruation. Dr. Apelo expects to implement this new sterilization method within 5 years. The center's objective is to support the National Population Program in its effort to reduce the country's population growth rate and promote family welfare. When the center was started, it occupied only 1 room of the hospital and was staffed by 1 full time doctor, 4 nurses, 4 midwives, 2 social workers, and 3 support staff. After 1 year of operation, the center recruited only 75 family planning acceptors. Information about the center's family planning services spread solely by word of mouth. During the 1st half of 1982, the center recruited 3490 acceptors of surgical and nonsurgical contraception, representing 96.94% of its 3600 target for the period. Minilaparotomy had the highest number of acceptors, 1742 or 49.92% of the total number of acceptors during the period. This was followed by the IUD with 1356 acceptors, OC, 245 acceptors; and other methods, 147 acceptors. In information and education, the center had 1882 motivational activities consisting of group discussions, ward lectures, field lectures, and mothers' classes. In training, the center conducted 10 courses, representing 100% of its target for the whole year. It trained doctors in performing voluntary surgical contraception and paramedics in assisting doctors in sterilization operations. The training courses were conducted under a subsidized contract with Popcom. The center also offers training in IUD insertion. In research, the center is active in investigating prospects for new contraceptive applications in the Philippine setting.     

Contraceptive use in China

A national sampling survey carried out in China in 1988 showed that 90.71% of the population were using some form of contraception: male sterilization (10.99%); female sterilization (38.24%); and IUDs (41.48%). Compared with 1982, the figures gathered in 1988 showed an increase in male sterilization and female sterilization and a decrease in condoms, oral or injected contraceptives, IUDs and spermicides. A great difference was found between the contraceptive methods used by women in rural areas as compared to women in urban areas. In urban areas IUDs accounted for 58%, female sterilization for 15%, male sterilization for 1% and condoms for 13%. In the country, female sterilization accounted for 42%, IUDs for 39%, male sterilization 15%, condoms 1% and oral contraceptives for 4%. There was also a strong difference between women of certain ages; the use of IUDs was highest among women between the ages of 15-29 years, while female sterilization was more prevalent for women over the age of 30. There was also a considerable difference between the birth control taken by women with children and those without; the majority of women (31%) without children used condoms; the majority of children (78%) with 1 child used IUDs; the majority of women (65%) with 2 children were sterilized. The sample study shows that 91% of the women using contraception used long-acting contraception.     

A survey of China's birth control among women of child-bearing age

To further implement China's family planning policy of "prevention first, birth control first," a study of the current family planning situation was conducted. A survey of the birth control methods employed by women of childbearing age and by men was based on a nationwide randomized sampling of 1/1000. In the different age groups, ranging from 15-49 years old, IUD users accounted for over 50%, tubal sterilization 25%, and vasectomy 10%. The main IUD users were women in the 20-24 age group. Tubal sterilization was more prevalent among the women in the 35-39 age group. The use of oral contraceptives (OCs) was more common among younger women but accounted for less than 10% of the total. The survey was based on the replies to questionnaires from 172,788 married women of childbearing age; 120,022 of them practiced contraceptive methods for a birth control rate of 69.46%. The breakdown was as follows: IUD, 34.84%; tubal sterilization, 17.63%; vasectomy, 6.94%; OCs, 5.86%; condom users, 1.39%; and other methods (including chemical suppositories, rhythm, or safe period method and withdrawal before ejaculation), 2.78%. There was a higher percentage of OC users in urban areas, and a marked preference for IUDs in the rural communities. The rural birth control rate was 68.58%; the urban rate was 74.17%. The use of the IUD has priority in all the areas; its percentage approaches the national average level. The use of vasectomy as a birth control method varies considerably according to area as does the use of OCs, condom, and tubal sterilization. Rural minority groups prefer the IUD and OCs; tubal sterilization, the condom, and vasectomy are preferred by the Han nationality. The birth control rate differed according to the different occoupation groups: 77.85%, workers; 76.01%, farmers; 85.15%, cadres; 59.52%, housewives; and 66.67%, others. The birth control rate was higher among those who received a college education than the illiterates, but statistics did not show a significant difference in the rate of those with a high school education and the illiterates. Mothers of 0-1 children generally preferred OCs; tubal sterilization was preferred by mothers with 2-3 children. The nonusers of contraception accounted for 30.54% among married women of childbearing age. A breakdown gives the following figures: menopause and infertility, 6.17%; divorced and widowed, 1.64%; planned parenthood, 10.51%; nonusers who should have practiced contraception, 12.22%. On a national level, the estimated number of nonusers of contraception among those who should be practicing contraception comes to about 20,000,000 women.     

Choosing a contraceptive method: why does it matter?

The use of contraceptives varies widely among Asian countries. Based on the most recent survey data available, the rate varies from nearly 8/10 married women aged 15-44 in Taiwan to fewer than 1/10 in Pakistan and Nepal. Women in East Asian countries are most likely to practice contraception, followed by those in Southeast Asia, with lower contraceptive prevalence rates found in South Asia. The rates of some East Asian nations now match those of the US and other developed nations, while in most South Asian nations contraception is spreading slowly. Contraceptive methods in use vary widely by country. The leading method in the greatest number of countries is sterilization, but in most countries several methods are nearly equal in popularity. Only in India is sterilization used by a majority of those people who practice contraception. Japan is the only country in which a majority of contraceptors use condoms, and only in China do 1/2 use IUDs. The choice of a particular contraceptive method is strongly influenced by 1) methods available through family planning programs, or promoted through the use of target systems; 2) religous and cultural factors; 3) concerns about side effects and safety; 4) ease of access to particular methods; 5) the medical profession; and 6) legality--in Japan the pill is illegal. In most countries the type of contraceptive that people prefer has changed since the introduction and promotion of modern methods of contraception. In general, there has been a shift to more effective methods. An increase in female sterilization at the expense of other methods such as the IUD or pill is the most common pattern. In countries where female sterilization is unpopular, use of such modern methods as the pill, IUD, or condom has increased at the expense of traditional methods.     

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.     

The family building life course and contraceptive use: Nang Rong, Thailand

This paper incorporates the insights of the life course perspective in an examination of the determinants of contraceptive use. It views decision-making about contraceptive methods in the context of personal history and the broader social setting. Three stages in the reproductive life course of married women are considered. In the early years, timing decisions dominate. Contraception is used to delay the first birth and control the tempo of fertility. Mid-career, the major concern is whether to have a sterilizing operation. Towards the end of the fecund period, couples must decide when to stop using contraception, given that they have not already opted for sterilization. We examine choice among nonpermanent methods, as well as sterilization, in the context of a theoretical model that explicitly recognizes the permanence of the sterilization decision. Our statistical procedures control for unobserved community influences. The data are from Nang Rong district, Thailand, a relatively poor area near the Cambodian border under going substantial socioeconomic change during the 1980s. Our results clearly show variation in method choice over the reproductive life course, and variation in the effects of specific determinants including age of husband and wife, living arrangements, and village location. They also demonstrate gains in the understanding of any particular stage in the life course that accrue from an integrated examination of all of them.     

Population momentum: A wider definition

Summary Keyfitz has derived an elegant formula for estimating the ultimate size of an initially stable, growing population that abruptly reduces its fertility to replacement level. Reduction of fertility is achieved by the rather unrealistic device of dividing the original age schedule nffertility rates by the net reproduction rate. Only the inertia of the age distribution is thus accounted for, but not that of the fertility schedule. The key idea of an abrupt imposition of a fixed regimen capable in the long run of generating zero population growth may be retained, but the regimen made more realistic. By elaborating the population setting, such disparate ZPG regimens as reduction of marital fertility by contraception, delayed and/or less universal marriage, raised mortality risks, or permanent net out-migration may be formulated. Convergence of the populaton to stationarity becomes a two-phase process: a primary adjustment period of changing fertility rates followed by a period of age adjustment. The present paper treats what happens when a fixed ZPG sterilization regimen, defined by a minimum age of sterilization γ and constant continuous risk φ of sterilization among unsterilized wives aged γ to β, is imposed abruptly (or else progressively over an interval T) upon an initially stable, growing population. Additional sources of residual growth are: (1) the nine-month lag in sterilization effect owing to pregnancy: (2) the more youthful pattern of child-bearing under sterilization: (3) the extra adjustment period (of length β-γ-0.75) of changing fertility rates; and (4) any delays in exposing elements of the population to the sterilization regimen. Two questions are pursued. First, how important are the additional sources of residual growth? Secondly, how do their relative sizes vary as a function of the characteristics of the initial population?     

Population momentum: A wider definition

Summary

Keyfitz has derived an elegant formula for estimating the ultimate size of an initially stable, growing population that abruptly reduces its fertility to replacement level. Reduction of fertility is achieved by the rather unrealistic device of dividing the original age schedule nffertility rates by the net reproduction rate. Only the inertia of the age distribution is thus accounted for, but not that of the fertility schedule. The key idea of an abrupt imposition of a fixed regimen capable in the long run of generating zero population growth may be retained, but the regimen made more realistic. By elaborating the population setting, such disparate ZPG regimens as reduction of marital fertility by contraception, delayed and/or less universal marriage, raised mortality risks, or permanent net out-migration may be formulated. Convergence of the populaton to stationarity becomes a two-phase process: a primary adjustment period of changing fertility rates followed by a period of age adjustment.

The present paper treats what happens when a fixed ZPG sterilization regimen, defined by a minimum age of sterilization γ and constant continuous risk φ of sterilization among unsterilized wives aged γ to β, is imposed abruptly (or else progressively over an interval T) upon an initially stable, growing population. Additional sources of residual growth are: (1) the nine-month lag in sterilization effect owing to pregnancy: (2) the more youthful pattern of child-bearing under sterilization: (3) the extra adjustment period (of length β-γ-0.75) of changing fertility rates; and (4) any delays in exposing elements of the population to the sterilization regimen.

Two questions are pursued. First, how important are the additional sources of residual growth? Secondly, how do their relative sizes vary as a function of the characteristics of the initial population?     

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.     

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.     

Use of contraceptives by Chinese women

In April 1985 the State Statistical Bureau of China conducted a fertility sampling survey in the provinces of Hebei and Shaanxi, and Shanghai municipality covering a population of 93,000,000. The target group was married women under 50 whose knowledge and use of contraceptives are the main content of this survey. The IUD has been used by 62% in Hebei, 61% in Shaanxi, and 55% in Shanghai, and is most popular with women over 30 who have had at least 1 child. Married women who have used the pill make up 33% in Shanghai, 14% in Hebei, and 7% in Shaanxi. Female and male sterilization are used by women who have had more than 2 children (15.7% in Shanghai, 40% in Hebei, and 28% in Shannxi). 70-80% have used contraception of some type, reflecting the success of the family planning program.     

Contraceptive sterilization in the U. S.: 1965 and 1970

There was an impressive increase between 1965 and 1970 in the prevalence of contraceptive sterilization, an increase that accelerated in the later years of the period and was shared in by virtually all subgroups considered. Among couples in 1970 for whom sterilization had been an option (recognizing that it is a terminal method), about one of every five had chosen this method of contraception. About half of all sterilizations were vasectomies, though vasectomies have outnumbered tubal ligations in recent years. Differentials in prevalence and in increases during 1965–1970 are reported for a number of life-cycle and social variables. In addition, a profile of the contraceptive sterile is presented for recent sterilizations. Significant proportions are relatively young and of low parity at the time of sterilization. In the context of the continued diffusion of the pill and IUD and increases in legal abortion, the net demographic effect of increasing sterilization is regarded as low, though sterilization is an important component of an effective fertility control regime.     

Philippines: total maternal care programme

The Total Maternity Care Programme, launched in June 1975 by the University of the Philippines at the Philippine General Hospital, aims at complete care for both mother and baby. Since the program began, requests for female postpartum sterilization have exceeded capacity. The postpartum ligation rate increased from 14% to 30% in a 6-month period. Reasons for this increase are word of mouth publicity, growing consciousness of the disadvantages of large families, and diseases contraindicating pregnancy. Reasons why women declined sterilization are mentioned. Based on the success of the program so far, it is recommended that Total Maternity Care Programmes be extended to the other maternity hospitals in metropolitan Manila.     

Communique of the National Sample Survey of Fertility and Birth Control (abstract)

The State Family Planning Commission in China surveyed 2,151,212 people, including 459,269 married women aged 15-57 on fertility and birth control, in July, 1988 from 30 provinces and other regions. From 1980- 87 the average total fertility rate was 2.47 vs. 4.01 in the 1970s. Fertility rates in the 80s were 1.33 for cities, 2.43 for towns, and 2.84 for villages. 1st parity births rose from 44.15% to 52.55% from Jan. to July of 1988 and 2nd parity births were about 30%. Women aged 50-57 had an average of 5.27 children while women aged 45-59 had an average of 4.44 children. 71.21% of childbearing-age women use contraception: 10.99% use male sterilization, 38.24% use female sterilization, 41.48% use IUDs, 4.91% oral pills, 2.65% condoms, 0.42% external contraceptives, and 1.32% use other methods. 13.79% of the married, childbearing-age couples have one-child certificates. The population of China as of April 1989 was 1.1 billion. In 1988 the birth rate was 20.78/1000 and the death rate was 6.58/1000.     

Backing seen of population policy in AID

Congress is almost certain to agree to use of U.S. funds to motivate reduced population growth in developing countries but funding for sterilization abroad emerged as a political issue in the House. In the proposed U.S. AID budget, which in the past has been about 10% funded for direct population programs, a total concern with literacy for women, higher educational levels, and other developmental programs which increase motivation for family planning has been proposed. Zero Population Growth has sent telegrams to Congress supporting this basic development policy. The controversy over sterilization is the result of India's compulsory sterilization legislation. An amendment refusing to allow any U.S. funds to be used for sterilization programs was rejected, but in rejecting it, the members of the House of Representatives expressed their concern that any and all sterilization programs be completely voluntary. In a letter, AID Deputy Administrator Robert Nooter assured Congress that AID has no goals to sterilize any certain number of women around the world and it is not the main purpose of the AID program to to emphasize sterilization as a method of family planning.     

Politics and Female Sterilization in Northeast Brazil

Brazilian fertility has fallen rapidly in the last three decades, even in the Northeast, the country's poorest region. Female sterilization has become the most common contraceptive method in this region, where 44 percent of married women aged 15–49 years were sterilized as of 1996. While in other regions sterilizations were generally paid for by the patient, politicians and physicians arranged and paid for the large majority of these surgical procedures in the Northeast. The authors present evidence that this phenomenon is the result of the use of sterilization as an electoral good by politicians and physicians in local contexts where politicians regularly provide goods and services to the poor in exchange for votes. This systemic behavior seems to have been little affected by 1997 legislation that regulated family planning, made sterilization legal, and was intended to increase the use of other methods of contraception.     

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.     

Can LARC Fulfill Its Potential to Reduce U.S. Women’s Unintended Pregnancy Risk? Examining Women’s Contraception and Childbearing in the Year Before Initiating LARC

Long-acting reversible contraceptives (LARCs) have received increased attention in recent decades for their potential to reduce the high level of unintended pregnancy. We know little about women’s contraceptive use and (unintended) childbearing prior to LARC initiation, even though it provides vital context to considering the extent to which increased LARC use could be expected to reduce the U.S. unintended pregnancy rate. Data from 849 women who initiated LARC in the 2–3 years prior to the 2006–2015 cycles of the National Survey of Family Growth were analyzed to describe U.S. women’s contraceptive use and (unintended) childbearing in the year before initiating LARC. Results show that more than half of women (55.4%) who initiated LARC did so within a year of giving birth, with 47.3% of these births resulting from an unintended pregnancy. Among women without a recent birth, 5.0% had last relied on sterilization, 54.7% had last used a moderately-effective method, 34.7% had last used a less-effective method, and 5.6% had not used contraception in the year prior to initiating LARC. These findings advance understanding of the extent to which increased LARC use could be expected to reduce the unintended pregnancy rate. Women initiating LARC after a recent birth are selective of those at high risk of unintended pregnancy. In contrast, the majority of LARC initiators without a recent birth last relied on a moderately-effective method or sterilization—a pattern that could reduce LARC’s impact on the unintended pregnancy rate.

     

Do Health Insurance and Residence Pattern the Likelihood of Tubal Sterilization among American Women?

American women have increasingly opted for tubal sterilization or tubal ligation surgery in recent decades. While research has begun to examine the unequal access to health care in the United States, little research has considered how this may impact whether women opt for a tubal ligation surgery. We first profile women with and without tubal ligations using bivariate analysis of the most recent data available, a nationally representative sample of 7,643 women from the National Survey of Family Growth, Cycle 6 (NSFG, Public use data file, 2002). We then use logistic regression models to examine the relationship between having tubal ligation and two focal variables: (1) type of health insurance (Medicaid compared with private, government or military, and no health insurance), and (2) rural or urban place of residence. We find that women on Medicaid are nearly twice as likely to have had a tubal sterilization compared with women who have private health insurance coverage. Also, women on Medicaid are substantially more likely to have a tubal sterilization than women with government or military insurance and women with no health insurance (26% and 36%, respectively). Further, we find that women living in rural areas are nearly twice as likely to have a tubal sterilization, compared with women in urban or suburban areas, all else being equal.     

Mortality risks,sequential decisions on births,and population growth

The population growth rates implied by parental attempts to be highly certain of having a surviving son for old-age support are investigated. At life expectancies of 40 to 65 years, family-planning “strategies” using contraception are found to imply markedly lower growth rates (1.01.5 percent vs. 2.5 percent) than are both commonly observed and also previously derived by Heer and Smith. In contrast to strategies relying only on sterilization, contraceptive spacing of births permits parents to buy time and information. In particular, they can postpone deciding whether to have another child until they see if their infant son will survive the earliest years of childhood. These results suggest that many less developed countries might achieve a substantial reduction in birth rates, provided that family-planning programs emphasized contraception as well as sterilization and effectively communicated the idea of spacing births. Factors bearing on the range of applicability of the old-age-security hypothesis, and any results and policies derived from it, are also briefly analyzed.