Adolescent pregnancy in the United States: a review and recommendations for clinicians and research needs.

Adolescent pregnancy, often unplanned and unwanted, has a negative impact on the physical, emotional, educational, and economic condition of the pregnant teenager. Forty percent of the one million adolescents who became pregnant in 1986 chose abortion, and, of the remainder, 61% were unmarried. Teenage mothers in greater numbers and at younger ages are opting to keep and raise their children. In 1987 over $19 billion in federal monies were expended on families begun when the mother was a teenager. The preferred approach to this problem is prevention of teenage pregnancy rather than abortion, with emphasis on sex education and access to family planning information and contraceptive devices for both females and males. Sex education in schools is presented in widely varying formats; in fact, prevention of pregnancy may not even be presented. Family planning clinics are subject to the whims and biases of the funding agencies. Clinicians have an important role in providing guidance for teenage patients and their parents, but can also influence school and community leadership to ensure that all teenagers receive sound sex education in school programs and that family planning agencies are permitted to counsel teenagers and provide contraceptive devices.

PIP: Of the close to 1 million teenagers in the US who became pregnant in 1986, over 470,000 opted to continue the pregnancy. 38% of these births were to females 17 years of age or younger, and 61% of the teen mothers were unmarried. Such untimely childbearing has substantial negative effects on the teenage mother's physical, emotional, educational, and economic condition. In addition, children born to such mothers experience compromised physical and intellectual attainment due to parental immaturity and the related economic and social instability. There are costs to society as well; in 1987, over US$19 billion in federal funds was spent to support families begun when the mother was a teenager. The most effective approach to this problem is prevention of teenage pregnancy through sex education, access to family planning information, and provision of contraception to both males and females. 30% of sexually active unmarried 15-19 year olds reported never-use of contraception in the National Survey of Family Growth, and this rate is higher among black adolescents. Although 60% of 12-17 year olds interviewed in 1986 reported receiving some form of sex education through the public schools, only a third had been exposed to a comprehensive presentation of reproduction, sexual development, and birth control. Use of family planning clinics is consistently associated with a large increase in the number of teenagers using more reliable forms of contraception such as the pill as well as substantial reductions in non-use of birth control. Authoritative guidance on the part of family planning providers has been shown to produce higher rates of contraceptive use than an independent decision-making style. Other pregnancy prevention strategies with documented potential include offering contraceptive information and prescriptions in secondary schools or a combination of sex education and counseling in the schools with services in a nearby free-standing location.

A study of women requesting interval contraceptive sterilization who do and do not return for surgery.

With the use of initial records of 1128 women who presented for interval tubal ligation, characteristics of those who were sterilized were juxtaposed with characteristics of those who did not return for surgery. Follow-up telephone interviews were conducted to explore regret after sterilization among 268 sterilized women. The subsequent histories of 144 women who did not return for surgery were examined, to determine whether failure to return might have screened, selectively, the women at greatest risk of regret. High levels of subsequent unwanted conception and pregnancy wastage were found in the nonreturn group. Institutional factors were often implicated in failure to return. Variables available at initial presentation are proposed to identify women who risk adverse consequences of postponed sterilization, to facilitate return without increasing regret.

Women's protective sexual behaviors: a test of the health belief model.

Heterosexual transmission of the human immunodeficiency virus (HIV) has become a significant health issue for women. The present study describes the extent to which a sample of women from an urban area report making efforts to protect themselves from becoming infected with HIV through several protective sexual behaviors. Secondly, we assess the extent to which adoption of these protective behaviors can be explained by health beliefs and previous HIV testing. Forty-nine percent of the sample reported having used a condom in the past year because of fear of AIDS and 48% reported having carried condoms. Women in this sample perceived themselves to be moderately susceptible to AIDS and they were well aware of the severity of the disease. Women tended to think that protecting themselves from AIDS would not be overly burdensome and that the recommended sexual protective behaviors were highly effective for preventing AIDS. Messages about the severity of AIDS and the effectiveness of protective sexual behaviors seem to be reaching women. Beliefs about personal susceptibility were consistently associated with the adoption of multiple protective behaviors, suggesting that messages emphasizing the ubiquity of risk, especially in demographically high-risk populations, may be particularly appropriate and effective.

PIP: The health belief structures that distinguish women who use condoms to protect themselves from themselves from the human immunodeficiency virus (HIV) and those who fail to take protective measures were investigated in a survey of 573 heterosexual women enrolled during their first prenatal visit to the Johns Hopkins Hospital Obstetrical Clinic. 90% of study subjects were African Americans, only 11% were currently married, and 65% were under 25 years of age. The proportions of respondents who had adopted any of the following 6 protective measures in the past year due to a fear of getting acquired immunodeficiency syndrome (AIDS) was the following: had fewer sexual partners (62%), had sex less often (48%), talked with a sex partner about AIDS (72%), decided to refuse sex because of concern a partner might be HIV-positive (47%), used condoms (49%), and carried condoms (48%). On the basis of the Health Belief Model of Janz and Becker, respondents were then questioned on their perceptions of susceptibility to AIDS, severity of the disease, barriers to condom use, and benefits of protected sex. Their mean scores on the preceding subscales, out of a maximum of 5.0, were 3.19, 4.08, 2.18, and 3.75, respectively. After adjusting for demographic factors and number of high-risk life-style practices, multiple regression analysis was used to determine the importance of these health beliefs to protective sexual behaviors. Beliefs about susceptibility and barriers emerged as the most significant correlates and were associated with having sex less often, deciding not to have sex, and carrying condoms. Condom use in the past year was correlated with beliefs about susceptibility, severity, and barriers. Overall, the findings suggest that women are motivated by feelings of personal susceptibility to try protective behaviors, but then conclude they are burdensome and discontinue.

Health belief and self-efficacy models: their utility in explaining college student condom use.

This investigation tested the ability of the Health Belief Model (HBM), dimensions of self-efficacy, various behavioral variables (i.e., number of sex partners in the past 12 months, frequency of drunkenness during sexual intercourse, and number of diagnosed sexually transmitted diseases), and demographic measures to distinguish between three condom user groups (i.e., nonusers, sporadic users, and consistent users). The usable sample consisted of 366 college students, ages 18 to 24. The study operationalized the following HBM components: perceived susceptibility, perceived benefits, and perceived barriers. The multidimensional Condom Use Self-Efficacy Scale (CUSES) was also used in this investigation. Results from a discriminant analysis indicated that sporadic users were best distinguished from both consistent and nonusers by number of sex partners in the past year, frequency of drunkenness during sexual intercourse, perceived susceptibility to HIV/AIDS and other STDs, and a self-efficacy factor labeled Assertive. The sporadic users had significantly more sex partners, were drunk more often when engaging in sexual intercourse, perceived themselves as more susceptible to HIV/AIDS and other STDs, and were less confident in their ability to discuss and insist on condom use with a partner. It was also discovered that each condom user group was best defined by different subsets of discriminating variables. Implications of these findings for campus-based prevention programs and future research are discussed.

PIP: The ability of the health belief model and self-efficacy concept to discriminate among three condom use groups--nonusers, sporadic users, and consistent users--was assessed in a sample of 366 sexually active college students 18-24 years of age. The mean number of sex partners in the 12 months preceding the survey was 2.2. The students could be classified as follows: nonusers, 70 (19%); sporadic users (defined as having more total sex partners in the preceding year than partners with whom a condom was always used), 157 (43%); and consistent users, 107 (29%), Principal components factor analyses of the health belief model constructs indicated that perceived benefits, perceived barriers, and perceived susceptibility are multidimensional. In univariate analyses, statistically significant differences across condom use groups were found for the following measures: perceived susceptibility of partner, perceived susceptibility of self, assertiveness, partner disapproval of condoms, intoxicants, number of sex partners, and inebriation during sexual intercourse. When a multiple discriminant function analysis was conducted with these variables, they failed to differentiate significantly between nonusers and consistent users but did distinguish sporadic users. Sporadic condom users perceived themselves and their partners as at highest risk of acquired immunodeficiency syndrome and other sexually transmitted diseases, had the largest number of sex partners in the past year, reported more inebriation during sexual intercourse, and were less confident in their ability to negotiate condom use with a partner than their counterparts in the other two use groups. Out of the variable subsets, the health belief model was best at identifying sporadic users, behavioral variables were most pertinent for nonusers, and the self-efficacy measure was most relevant in the case of consistent use.

Acceptance of contraceptive practice by grandmultiparae in Benin City, Nigeria.

Five hundred sixty grandmultiparous women were interviewed as to their contraceptive awareness, desirability and use in the three major hospitals in Benin City, Nigeria, between October 1, 1980 and September, 1981. Their parity ranged from 5 to 14 with a mean of 6.7. There was high level of awareness of contraceptive availability and usefulness (65%), but low level of practice (27.1%). The main causes of the low practice level included opposition from husband and other relatives, complications of previous methods used and the desire to have a large family. Oral contraceptives were the preferred method, followed by intrauterine devices. Educational attainment had a positive relationship to acceptance of contraceptive practice. We believe that with more concerted effort at family planning counseling, the community will be rid of the hazards and menace of grandmultiparity.

PIP: 560 grandmultiparous women were interviewed as the their contraceptive awareness, desirability and use in the 3 major hospitals in Benin City, Nigeria, between October 1, 1980 and September, 1981. Their parity ranged from 5 to 14 with a mean of 6.7. There was a high level of awareness of contraceptive availability and usefulness (65%), but a low level of practice (27.1%). The main causes of the low practice level included opposition from the husband and other relatives, complications of previous methods used and the desire to have a large family. Oral contraceptives were the preferred method, followed by intrauterine devices. Educational attainment had a positive relationship to acceptance of contraceptive practice. A more concerted effort at family planning counseling will rid the community of the hazards of grandmultiparity. Questionnaire interviews were used to conduct the study. All the interviews were conducted by medical personnel. 201 subjects were interviewed in late pregnancy, 40 intrapartum and 319 in the early puerperium. Societal pressure to have male children was found to be a hurdle for contraceptive use. Male opposition to contraception, particulary among men in the lower socioeconomic groups, is a problem that needs to be addressed by policy makers. There is an urgent need for a national policy on family planning. As an incentive, there should be mass availability of all types of contraceptive devices free of charge to users or at least highly subsidized. Education influences that age at marriage and 1st childbirth and increases acceptance of contraceptive practice.

Contraceptive practices of teenage mothers.

PIP: This study explores the contraceptive attitudes and practices of a sample of adolescent mothers who participated in a teen parents project at Howard University. Members of the sample were interviewed 3 times; twice prior to their entry into the intervention program and once afterwards. Concern over the side effects of contraceptives was the primary reason that mothers in this sample gave for not using contraception at the time they became pregnant. Motivational factors were secondary, and lack of information about contraception and fertility ranked 3rd. Recommendations are made for the dissemination of more complete information about contraceptive methods to inner city adolescents and for closer follow-up of teenage clients from family planning facilities.^ieng

Social and psychological correlates of pregnancy resolution among adolescent women: a review.

A review of the recent literature on pregnancy resolution among unmarried adolescent women suggests that those who seek and go through with an abortion do not comprise a "special" population, but are similar to their age mates in many of their social and psychological characteristics. Previous research does suggest, however, that teenage abortion patients differ from their term counterparts on a number of significant variables.

PIP: The sociodemographic profile of the unmarried adolescent abortion patient appears to be somewhat distinctive from that of her counterpart who carries her pregnancy to term. She is slightly older, of higher social class, better educated, more financially independent, and more likely to be white. These characteristics suggest that the circumstances of the adolescent abortion patient are more favorable than those of her term counterpart, for whom pregnancy inevitably results in social and economic hardships. Some of the psychological correlates of pregnancy are intentions, attitudes, and beliefs, as well as various personality characteristics. In general, reports on adolescent fertility have emphasized the social and economic problems of women who carry their pregnancies to term. Some studies stress the psychological effects of almost certain disruption of schooling and other 'life schedule' events. The social and psychological costs of unmarried adolescent childbearing appear to be great and may effect the mother's psychological well-being, limit her prospects for the future, and restrict life chances of her offspring.

Contraceptive use among women admitted with abortion in Nairobi.

In this study, a total of 519 patients were interviewed. 82.5% had incomplete abortion. The implication of abortion especially when induced is emphasised. Economic implications that are contributed by the youth are stressed. 83.6% of the patients had not used any contraception. The role of contraception in preventing unwanted pregnancy and therefore induced abortion is stressed. The role of the physician in providing contraception and appropriate contraceptive knowledge is discussed.

PIP: A study of 519 consecutive women admitted to Kenyatta National Hospital with the diagnosis of abortion revealed that the majority were young and had a history of nonuse of contraception. Abortion was incomplete in 428 (83%) of cases; 60 (12%) cases involved sepsis. Women 20-24 years of age accounted for 221 (43%) of the abortions; the other two most represented age groups were 25-29 years (28%) and 14-19 years (17%). 460 (89%) of the abortion patients had never used a contraceptive method. The most frequently cited reasons for nonuse were desire for pregnancy (48%), no conscious reason (13%), procrastination in getting to a family planning clinic (8%), no knowledge of family planning (6%), and fear of side effects (6%). Of the 64 cases of failed contraception, 27 were using the pill, 25 had an IUD in place, and 8 were relying on the rhythm method. Among contraceptive users, the major sources of information about contraception were nurses (52%), radio and newspapers (19%), and other women (15%). Only 4% indicated that a physician had discussed family planning with them. Given the resource drain that treatment of incomplete abortion can place on Kenya's health care system and the risk of abortion-induced pelvic infection and subsequent infertility, Kenya's health workers should be encouraged to be more aggressive in promoting family planning use among young women.

Reasons for non-use of family planning methods at Ilorin, Nigeria: male opposition and fear of methods.

This study reports the main reasons given for non-use of contraception by non-pregnant women aged 15-44 years, who are at risk of unplanned pregnancy and living in the Ilorin Local Government Area of Kwara State, Nigeria. Six hundred and forty-six women were derived from a stratified cluster sample and interviewed using a questionnaire. Almost one-third (31.4%) of respondents gave male opposition to family planning as the reason for current non-use. Another 13.3% expressed fear of methods, 6.3% did not want to use contraception until the first child was born, and 13.6% until the desired number of children were born. Sociodemographic variables including age, educational level, religion, and residence as reasons for non-use were reported. Other important findings included a high awareness of, low availability of, or poor accessibility to contraceptive methods. Short and long term intervention strategies using information, education and communication materials are proposed to combat low levels of contraceptive use in this area.

PIP: This study addresses the main reasons for non-use of contraception by non-pregnant sexually active females. A survey was carried out in Ilorin area of Nigeria where household units were randomly selected by using a clustering method sampling frame. Data was collected from personal interviews on 646 women. 79% of the women were between 20-39 yrs, 77% were Moslems, 67% had no formal education and 84% of the women were married. The average total fertility rate was 4.8 live births per woman, and a mean abortion rate of 1 per woman. All women reported to be knowledgeable on the use of contraceptives and the supply source, although only 27% of the women had previously used contraceptives. Reasons for non-use of contraceptives included 1) husband's rejection of contraceptive method, and 2) fear of method of contraceptives. Also a higher % did not use contraceptives until the first baby born. Thus it was proposed that long and short term methods needed to be used to combat non-use of contraception. A long term strategy should address the male perception of family planning and womanhood, whereas the short term strategy could address issues concerning the safety of contraceptives and dispel myths and negative rumors with regards to contraceptives.

Estimating coverage from routine information.

PIP: A study was conducted in Buhera district, Zimbabwe, to estimate coverage of health services by relating routinely collected health statistics to census data. Buhera is a relatively underdeveloped district, with health services provided by a district hospital, 2 rural hospitals, 12 health centers and 50 mobile clinics. Data were collected concerning the number of individuals making outpatient visits, antenatal visits and vaccinations per month for each catchment area. Overall, there were 69 new outpatient visits/100 people in the catchment area per year. Several areas were found to have much lower rates, and this was linked to areas with high membership in the Apostolic Church, a group that forbids medical treatment. There were 43 new antenatal visits/100 pregnancies. Low rates were linked to areas with no female medical assistants. 32% of children under 1 year of age were vaccinated against measles. Low vaccination rates were linked to Apostolic Church membership. In a cluster survey, 36% of respondents cited religious beliefs as the reason for incomplete immunization. Routine health statistics were found to underestimate vaccination rates by 25%. This was attributed to incomplete recording and forms being lost. Analysis of routine data is believed to provide useful information that may allow identification of underserved areas and of barriers to health care utilization.^ieng

Attitudes, knowledge, and behavior regarding condom use in urban black adolescent males.

This study was conducted to determine male adolescent behavior, attitudes, and knowledge concerning the use of condoms. Subjects were 241 sexually active black adolescent males attending an inner-city adolescent medicine clinic who were surveyed using a structured interview technique. Factors associated with condom use included higher grade level, > or = 2 sexual partners in the past six months, communication about contraception with sexual partner(s), desire for sexually transmitted disease (STD) prevention when contracepting, and parental suggestion to use condoms. Variables not associated with condom use included older age, minimal level of knowledge about condom use, history of having impregnated a partner or of having contracted an STD, desire for pregnancy prevention, suggestion by friends to use condoms, or partner dissatisfaction with condoms. Using multivariate logistic regression analysis, the following variables in combination were able to correctly classify respondents as condom users or nonusers in 74% of cases: higher knowledge score, reported communication about contraception with one's partner(s), > or = 2 partners in the past six months, and higher socioeconomic status. These findings suggest that, for the study population, interventions directed toward improving knowledge about condoms, school achievement, and communication with parents and partners may be effective in increasing condom use.

PIP: Structured interviews with 241 sexually active Black adolescent males attending an adolescent medicine clinic in Washington, DC, yielded useful data on factors associated with condom use in this population group. The average age of subjects was 16.2 years and they had completed an average of 10th grade. 90% of parents were employed, generally in jobs providing clerical and administrative support. Average age at first intercourse was 12.4 years. 56 (23.1%) had a prior history of a sexually transmitted disease (STD) and 46 (19.0%) had impregnated a sexual partner. 208 males (86.0%) has ever used contraception and 163 (67.4%) had used condoms at some point. Among the ever-users, 109 (52.4%) identified condoms as their method of preference. Condom use was significantly associated with education beyond the 9th grade and higher socioeconomic status; it was not correlated with increased age or level of knowledge regarding condoms. Males who had 2 or more sexual partners in the 6 months preceding the interviews were more likely than those who had 0 or 1 partner to report condom use, but a history of STDs or impregnation of a sexual partner did not significantly increase this likelihood. Discussions with sexual partners about contraception, but not sex, prior to intercourse also increased condom usage. Males who used contraception to avoid STDs or to follow parental suggestion were more likely to use condoms than those primarily concerned with pregnancy prevention. Finally, multivariate logistic regression analysis indicated that a combination of 4 factors--higher knowledge score, 2 or more sexual partners in the preceding 6 months, higher socioeconomic status, and communication about contraception with sexual partners--correctly classified subjects as condom users or nonusers in 74% of cases. Overall, these findings confirm the acceptability of condom use among Black adolescent males, especially if an emphasis is placed on their ability to protect against STDs.

Contraceptive intention behavior in rural Bangladesh: factors in the diffusion of an innovation.

PIP: To elucidate the determinants of contraceptive use or nonuse in rural Bangladesh, Fishbein's behavioral intention model was modified and applied to survey data collected in 1984 in the Ghatail upazila of the Tangail district. The proposed behavioral model consists of 5 independent variables: global attitude, global motivation to comply, motivation toward fertility regulation, method-specific attitude, and method-specific availability. Of the 193 respondents surveyed, 152 expressed an intention not to use oral contraceptives (OCs)--the most accessible method in the survey area--and were generally negative about any form of contraceptive use. As expected, the 41 women who did intend to use OCs had a positive global attitude toward contraception. Global motivation to comply scores were negative for women who had no plans to become OC users, largely because of a belief that the Islamic religion prohibits contraceptive use. Concern about religion was a greater obstacle to these women than the perceived reaction of their husband and friends to OC use. The aggregate score on motivation for fertility regulation was positive, suggesting that respondents still desire more children. The pill received a negative method-specific score due to perceptions that it is unreliable and causes side effects. The mean distance to a source of OCs (method availability) was 2.55 miles among women who intended not to use the pill and 2.34 miles among potential acceptors. Stepwise logistic regression analysis indicated that global attitude and global motivation were the most significant predictors of intent to use OCs; the only other significant variable was method-specific attitude. The implications of these findings are that contraceptive availability is not sufficient to contraceptive use; creation of a favorable attitude toward contraception and support from Islamic religious leaders appear to the necessary prerequisites to more widespread fertility control.^ieng

A study of vasectomized men and their wives.

PIP: The Kuhn and McPartland questionnaire, designed to elicit information on self concepts, was sent to 50 vasectomy patients, to the patients' wives, and to 50 control couples who used other forms of contraception. Data on the demographic characteristics of the vasectomy patients and on their attitudes toward vasectomy, 6 months-5 years following the operation, was also collected. Vasectomized men were significantly more free from social constraints and more independent then the other respondents. The controls and the wives of the vasectomized men tended to view themselves in the context of structured relationships and were more conforming than the vasectomized men. Vasectomized men and their wives, therefore, differed in regard to their self concepts while controls and their wives had similiar self concepts. On the basis of this finding it was predicted that vasectomy would become increasingly popular in Australia. Since husbands and wives in Australia tend to have divided roles, it can be assumed that most Australian husbands and wives differed in their self concepts. These couples will, therefore, choose vasectomy as a form of birth control once they complete their families. Following vasectomy, the health of 43.6% of the wives of the vasectomized men improved while only 2.5% of the vasectomized males reported an improvement in their health. All of the wives were happy about their husbands vasectomies and said they would recommend the operation to others. Men who usd condoms were more likely to seek vasectomy than men who did not use condoms. The average age of the vasectomized males was 37.82 years and the average duration of marriage prior to vasectomy was 13.02 years.^ieng

A family planning study in Kuala Pilah, Peninsular Malaysia.

PIP: Realizing that family planning is not making a sufficient impact on the rural people as it is on the urban population, it was decided that the authors would study the attitude and knowledge of a rural community towards family planning. The study sample consisted of 200 Malay married women--100 acceptors and 100 nonacceptors from the Kuala Pilah District. The study went from December 4-22, 1978. A healthy climate of knowledge and attitude exist among rural Malay women. Only 2% of the nonacceptors had not heard of any family planning method; 99% of acceptors and 85% of nonacceptors had discussed family planning with their husbands. There was also evidence to show that the birthrate does decrease as literacy increases. On the other hand, however, only 19% of the respondents approved of family planning practices prior to the birth of the 1st child. Also, there is a dearth of information on family planning in the rural areas and not much has been done in utilizing the 2 popular forms of mass media--radio and television as a means of disseminating information on family planning. The study concludes with a recommendation that there is a need for a sustained effort at improving knowledge and disseminating information as well as for developing the proper attitude towards family planning. It is suggested that community leaders, women's clubs, and private organizations be mobilized to participate more fully in the promotion of family planning.^ieng

[The critical period in natural fertility]. / El periodo crítico de la fertilidad natural.

In order to learn the natural expectancy period of first pregnancy as well as the influences of some biosocial variables, a clinical-retrospective study was performed within 1120 gravida I women. All of them attended the major institutes of health care in Mexico City (IMSS, ISSSTE, SS and DDF). Data were obtained by means of predetermined questions from subjects after the first postpartum hours. None of them had previously used any contraceptive method. Results showed age at the first pregnancy: 21.6 +/- 3.8 (years); gestational interval 22.1 +/- 19.9 (months) and a 67% achievement rate the following twelve months of sexual activity. Eutocia was seen in 54% of these population and significant linear correlation was attained between age of the patient and the gestational interval. It seems that this is the first information regarding the fertility critical period within our society.

PIP: The interval between first intercourse and pregnancy and the influence on it of various biosocial variables were studied in 1120 women who gave birth in maternity centers in Mexico City belonging to the Mexican Institute of Social Security (IMSS), the Institute of Social Security Services for State Workers (ISSSTE), the Secretariat of Health (SS), and the Medical Services of the Department of the Federal District (DDF). Women who had used contraceptives or who had a history of infertility or of endocrine or metabolic diseases were excluded. Data were obtained by means of questionnaires administered postpartum. The average age of the women was 22 + or - 4 years. 60% were married and 40% single. 41% were housewives and 59% were employed. 2% were illiterate, 22% had primary educations, 48% had secondary educations, and 8% were professionals. The average age at menarche varied from 12 to 13 years. Average age at first intercourse was 20 + or - 4 for the IMSS, 22 + or - 4 for the ISSSTE, 18 + or - 3 for the SS, and 17 + or - 2 for the DDF subsamples. The average age at first pregnancy was 21.6 + or - 2.8 years, and the average gestational interval was 22.1 + or - 19.9 months. But 67.5% of the total sample became pregnant in the 12 months following first intercourse, as did 82.9% of the SS and 86.3% of the DDF subsamples. The interval between first intercourse and first pregnancy was 8 years or more for 1-2% of the sample in each institution. 36% of women in the IMSS group, 73% in the SS and DDF groups, and 77% in the ISSSTE group had normal vaginal deliveries. 18% in the ISSSTE, 21% in the SS and DDF, and 51% in the IMSS groups had Cesarean deliveries.

A study of acceptors and non-acceptors of family planning methods among three tribal communities.

PIP: Primary data were collected from 399 currently married women of the Marati, Malekudiya, and Koraga tribes in the Dakshina Kannada district of Karnataka State in this study of the implementation of family planning programs in tribal areas. The Marati, Malekudiya, and Koraga tribes are three different endogamous tribal populations living in similar ecological conditions. Higher levels of literacy and a high rate of acceptance of family planning methods, however, have been observed among these tribes compared to the rest of the tribal population in the state. 46.4% of currently married women aged 15-49 years in the tribes were acceptors of family planning methods, having a mean 3.7 children. The majority of acceptors opted for tubectomy and vasectomy. The adoption of spacing methods is less common among tribal people. Most acceptors received their operations through government health facilities. They were motivated mainly by female health workers and received both cash and other incentives to accept family planning. The main reason for non-acceptance of family planning among non-acceptors was the desire to conceive and bear more children. The data indicate that most of the tribal households are nuclear families with household size more or less similar to that of the general population. They have a higher literacy rate than the rest of the tribal population in the state, with literacy levels between males and females and between the three tribes being quite different; the school enrollment ratio is relatively higher for both boys and girls.^ieng

The other side of abortion.

PIP: India's 1962 Medical Termination of Pregnancy Act allows abortions to be performed up to 20 weeks of gestation on medical, humanitarian, or eugenic grounds. Of the 406 million abortions that occur in India each year, 2.3 are induced. Women who obtain an induced abortion tend to be 21.30 years old, married, have at least 2 living children, are of relatively low educational status, are from the middle or lower socioeconomic strata, and are nonusers of contraception. Thus, abortion in India comprises a major method of fertility control; up to 80% of abortion patients were not using contraception. This phenomenon is extremely costly; an abortion costs about Rs 350, while 1 couple-year of contraceptive protection averages Rs 60. Induced abortion also carries psychological costs. Although the majority of abortion acceptors experience relief after the procedure, guilt, depression, and social and occupational sequelae are not uncommon. Moreover, women with adverse psychological reactions to abortion are at risk of nonuse of contraception and a repeat pregnancy. Women most at risk of an adverse psychological reaction to abortion are those who are unmarried, adolescents, strongly religious, and are undergoing the procedure against their wishes. While access to abortion should be protected in India, greater attention should be given to the factors that make it necessary, including illiteracy, nonavailability or lack of knowledge of contraceptive methods, inadequate follow-up of contraceptive acceptors, and poor motivation.^ieng

Vaccine perception among acceptors and non-acceptors in Sokoto State, Nigeria.

Vaccine perceptions among acceptors and non-acceptors of childhood vaccination were explored. Seventy-two care givers, among them, acceptors and non-acceptors were interviewed in-depth with an interview guide that assessed vaccine acceptance, social and personality factors, and health belief model (HBM) categories in relation to oral polio vaccine (perceived susceptibility, severity, cost barriers, general barriers, benefits, knowledge, and engagement in preventative health behaviours). Community leaders were purposively selected while parents were selected on the basis of availability while ensuring the different attitude to vaccines was covered. Results showed that the HBM framework was found to be appropriate for identifying and distinguishing vaccine acceptors and non-acceptors. In addition, the HBM categories of benefits and susceptibility were found to influence oral polio vaccine acceptance. Second, the opinion of family members about the oral polio vaccine moderated the relationship between number of social ties and vaccine acceptance. Further, oral polio vaccine acceptance was related to outbreaks of paralysis of any sort, but not aggregate scores of other preventative health behaviours. Implications of this study include the investigation of vaccine acceptance in a high risk population. Research was done to investigate vaccine acceptance.

Barriers in family planning.

PIP: Because of cultural factors, many people in India are opposed to family planning. They are not able to understand that the real problem facing India is overpopulation. In the past, people were exhorted to have many children, and to look upon numerous offspring as a blessing, and this concept has not changed, although the times and environment have. The majority of marriages in rural areas take place when the girl is hardly 16 or 17, which contributes to high fertility. Also illiteracy breeds ignorance about improved methods of cultivation and about methods of planned parenthood. Starved, poor couples have larger numbers of children than do well-to-do families, and thus poverty becomes a vicious circle. Doctors should come forward and offer their help to family planning programs, and social workers should be less concerned with official routines than results. Educating illiterate, adamant people is no easy task, and requires the zeal of a missionary.^ieng

[Psychosomatic effects of oral contraception]. / Effetti psicosomatici della contraccezione orale.

PIP: The authors gathered information from 242 respondents by means of a questionnaire on the body, psychophysical, and psychosexual changes resulting from oral contraceptive (OC) use. Group 1 (n=12) were examined at the Obstetric/Gynecology Clinic at Naples University and group 2 (n=140) at the Ordinary Ambulartory Clinic at the same institution. The motivations for contraceptive refusal were also examined. Analysis of the results noted a clear prevalence of psychosomatic effects in the 1st group as compared to the 2nd which evidenced a greater number of deep social-cultural problems. (author's modified)^ieng