Misconceptions, Misinformation, and Misperceptions: A Case for Removing the "Mis-" When Discussing Contraceptive Beliefs.

Beliefs about contraception are commonly conceptualized as playing an important role in contraceptive decision-making. Interventions designed to address beliefs typically include counseling to dispel any "myths" or "misconceptions." These interventions currently show little evidence for impact in reducing beliefs. This commentary delves into the problems associated with using implicitly negative terminology to refer to contraceptive beliefs, which come laden with assumptions as to their validity. By conceptualizing women as getting it wrong or their beliefs as invalid, it sets the scene for dubious treatment of women's concerns and hampers the design of fruitful interventions to address them. To replace the multitude of terms used, we suggest using "belief" going forward to maintain value-free curiosity and remove any implicit assumptions about the origin or validity of a belief. We provide recommendations for measuring beliefs to help researchers understand the drivers and impacts of the belief they are measuring. Finally, we discuss implications for intervention design once different types of belief are better understood. We argue that tailored interventions by belief type would help address the root causes of beliefs and better meet women's broader contraceptive needs, such as the need for contraceptive autonomy and satisfaction.

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study.

BACKGROUND: An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes. METHODS: The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight. RESULTS: Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention. CONCLUSIONS: We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of disability and mortality globally. Premature fatal and non-fatal CVD is considered to be largely preventable through the control of risk factors by lifestyle modifications and preventive medication. Lipid-lowering and antihypertensive drug therapies for primary prevention are cost-effective in reducing CVD morbidity and mortality among high-risk people and are recommended by international guidelines. However, adherence to medication prescribed for the prevention of CVD can be poor. Approximately 9% of CVD cases in the EU are attributed to poor adherence to vascular medications. Low-cost, scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity, mortality and healthcare costs associated with CVD. OBJECTIVES: To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two other databases on 7 January 2020. We also searched two clinical trials registers on 5 February 2020. We searched reference lists of relevant papers. We applied no language or date restrictions. SELECTION CRITERIA: We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD. We only included trials with a minimum of one-year follow-up in order that the outcome measures related to longer-term, sustained medication adherence behaviours and outcomes. Eligible comparators were usual care or control groups receiving no mobile phone-delivered component of the intervention. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane. The main outcomes of interest were objective measures of medication adherence (blood pressure (BP) and cholesterol), CVD events, and adverse events. We contacted study authors for further information when this was not reported. MAIN RESULTS: We included 14 trials with 25,633 randomised participants. Participants were recruited from community-based primary and tertiary care or outpatient clinics. The interventions varied widely from those delivered solely through short messaging service (SMS) to those involving a combination of modes of delivery, such as SMS in addition to healthcare worker training, face-to-face counselling, electronic pillboxes, written materials, and home blood pressure monitors. Some interventions only targeted medication adherence, while others additionally targeted lifestyle changes such as diet and exercise. Due to heterogeneity in the nature and delivery of the interventions and study populations, we reported most results narratively, with the exception of two trials which were similar enough to meaningfully pool in meta-analyses. The body of evidence for the effect of mobile phone-based interventions on objective outcomes of adherence (BP and cholesterol) was of low certainty, due to most trials being at high risk of bias, and inconsistency in outcome effects. Two trials were at low risk of bias. Among five trials (total study enrolment: 5441 participants) recording low-density lipoprotein cholesterol (LDL-C), two studies found evidence for a small beneficial intervention effect on reducing LDL-C (-5.30 mg/dL, 95% confidence interval (CI) -8.30 to -2.30; and -9.20 mg/dL, 95% CI -17.70 to -0.70). The other three studies found results varying from a small reduction (-7.7 mg/dL) to a small increase in LDL-C (0.77 mg/dL). All of which had wide confidence intervals that included no effect. Across 13 studies (25,166 participants) measuring systolic blood pressure, effect estimates ranged from a large reduction (MD -12.45 mmHg, 95% CI -15.02 to -9.88) to a small increase (MD 2.80 mmHg, 95% CI 0.30 to 5.30). We found a similar range of effect estimates for diastolic BP, ranging from -12.23 mmHg (95% CI 14.03 to -10.43) to 1.64 mmHg (95% CI -0.55 to 3.83) (11 trials, 19,716 participants). Four trials showed intervention benefits for systolic and diastolic BP with confidence intervals excluding no effect, and among these were all three of the trials evaluating self-monitoring of blood pressure with mobile phone-based telemedicine. The fourth trial included SMS and provider support (with additional varied features). Seven studies (19,185 participants) reported 'controlled' BP as an outcome, and intervention effect estimates varied from negligible effects (odds ratio (OR) 1.01, 95% CI 0.76 to 1.34) to large improvements in BP control (OR 2.41, 95% CI: 1.57 to 3.68). The three trials of clinician training or decision support combined with SMS (with additional varied features) had confidence intervals encompassing benefits and harms, with point estimates close to zero. Pooled analyses of the two trials of interventions solely delivered through SMS were indicative of little or no beneficial intervention effect on systolic BP (MD -1.55 mmHg, 95% CI -3.36 to 0.25; I2 = 0%) and small increases in controlled BP (OR 1.32, 95% CI 1.06 to 1.65; I2 = 0%). Based on four studies (12,439 participants), there was very low-certainty evidence (downgraded twice for imprecision and once for risk of bias) relating to the intervention effect on combined (fatal and non-fatal) CVD events. Two studies (2535 participants) provided low-certainty evidence for the effect of the intervention on cognitive outcomes, with little or no difference between trial arms for perceived quality of care and satisfaction with treatment. There was moderate-certainty evidence (downgraded due to risk of bias) that the interventions did not cause harm, based on six studies (8285 participants). Three studies reported no adverse events attributable to the intervention. One study reported no difference between groups in experience of adverse effects of statins, and that no participants reported intervention-related adverse events. One study stated that potential side effects were similar between groups. One study reported a similar number of deaths in each arm, but did not provide further information relating to potential adverse events. AUTHORS' CONCLUSIONS: There is low-certainty evidence on the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD. Trials of BP self-monitoring with mobile-phone telemedicine support reported modest benefits. One trial at low risk of bias reported modest reductions in LDL cholesterol but no benefits for BP. There is moderate-certainty evidence that these interventions do not result in harm. Further trials of these interventions are warranted.

Exploring the Demand-Side Factors Associated with the Use of Implants in Kenya.

We explore the demand-side factors associated with the use of implants in Kenya given the notable rapid increase in uptake of the method in the country. Data are from a longitudinal study conducted among married or cohabiting women aged 15-39 years at the time of recruitment in one rural (2,424 women) and one urban (2,812 women) site. Analysis entails descriptive statistics and estimation of multivariate logistic regression models. The results show that the key demand-side factors associated with the use of implants were low discontinuation of the method compared with alternatives and strong motivation on the part of the women for long-term spacing of births. However, implants had no perceived advantages over the main alternative methods in terms of beliefs about possible damage to health or unpleasant side effects or in terms of satisfaction with use. The findings suggest that addressing concerns about safety for long-term use and for health may increase demand for implants in particular and long-acting reversible contraceptives in general in the study settings or in similar contexts, especially among women who desire long-term spacing of births.

Fertility preferences and subsequent childbearing in Africa and Asia: A synthesis of evidence from longitudinal studies in 28 populations.

Survey data on fertility preferences have played a central but controversial role in fertility research and advocacy for family planning. We summarize evidence from longitudinal studies in 28 Asian and African populations on the relationship between preferences and subsequent childbearing. While we found no consistent association between women's desire to delay childbearing and subsequent fertility, the baseline desire of women to stop childbearing was a powerful predictor of subsequent fertility in all populations and increased in strength as overall contraceptive use in the study populations rose. Partners' desire also exercised some influence but was of modest importance in most populations. However, the correspondence between desire to stop and behaviour was found to be far from perfect. Weak implementation of preferences by contraception is likely to be the major cause of this preference-behaviour discrepancy. Uncertainty and instability in preferences may also contribute to the discrepancy, particularly in sub-Saharan Africa.

Childbearing desires and behaviour: a prospective assessment in Nairobi slums.

BACKGROUND: Advancing an understanding of childbearing desires is an important precursor to achievement of the policy goal of reducing unintended pregnancies. It has been long debated that concepts of fertility desires and planning may be particularly problematic in sub-Saharan Africa. However, examination of the utility of fertility preference measures and their link to reproductive behaviour is still rare in the region. The aim of this study is to assess the predictive validity of future childbearing desires on subsequent reproduction among women living in the highly unpredictable circumstances of Nairobi slums. METHODS: We used data from a longitudinal study (2007-2010) nested in the Nairobi Urban Health Demographic Surveillance System that is located in two slums in Nairobi, Kenya. We analysed baseline fertility desires among 4577 postpartum women. Cox proportional hazard model was employed to examine the effect of fertility desires on subsequent reproduction. RESULTS: One-third of the women wanted no more children and 37% wanted to wait for at least five years at baseline. While two-thirds of the women who wanted to have a child soon became pregnant within three years, less than one-third of those wanting no more children became pregnant. The multivariable analysis shows that the probability of becoming pregnant among women who expressed desires to stop or delay childbearing at least for five years was 50% less than among women who wanted to have a child in two to four years. In addition to prospective fertility desires, level of woman's education, residence and ethnicity exerted important influences on implementation of baseline preferences. CONCLUSIONS: Our study finds a strong link between baseline fertility desires and subsequent reproduction. A large difference in pregnancy risk was observed between those who wanted no more children and those who wanted another child. The link between a woman's stated desire to stop childbearing and subsequent childbearing is just as strong in the Nairobi slums as elsewhere. In addition, the findings revealed a pronounced gradient in pregnancy risk according to preferred spacing length, which support other evidence on the important contribution of long-term spacing or postponement to fertility decline in sub-Saharan Africa.

Factors influencing satisfaction with oral contraceptive pills and injectables among past users in Kenya.

This study examines factors associated with satisfaction with oral pills and injectables among past users in Kenya based on a baseline survey for the 2-year prospective longitudinal study Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning conducted in 2016. Married women aged 15-39 years were interviewed using a structured questionnaire that captured information on reproduction, contraceptive knowledge and beliefs and attitudes towards contraception in general and towards specific methods. A multivariate logistic regression analysis was used to examine factors that influenced satisfaction with oral pills and injectables among past users in one urban site (Nairobi slums) and one predominantly rural site (Homa Bay in western Kenya). Results showed that dissatisfaction with pills and injectables is common among past users in both rural and urban Kenya (ranging from 39% to 56%). The distinctive contribution of the study lies in its ability to relate method-specific beliefs to overall satisfaction. Perception of effectiveness, ease of use and safety for long-term use had statistically significant influences on satisfaction with pills in both urban and rural sites while partner's approval was only important in Nairobi. For injectables, the perception of safety for long-term use was significant in the urban but not the rural site. Unlike pills, the belief that members of a woman's social network had used a method and found it satisfactory was a particularly powerful influence on satisfaction (AOR=2.8 in rural and 3.2 in urban). Perception of accessibility and fears about infertility were not found to be statistically associated with satisfaction for either pills or injectables. Surprisingly, the effects of all perceived contraceptive attributes were the same for major socio-demographic strata of the populations. The findings underscore the need for targeted counselling and community-based communication interventions to address negative and erroneous perceptions about family planning methods.

Method-Specific Attributes that Influence Choice of Future Contraception Among Married Women in Nairobi's Informal Settlements.

Despite an extensive evidence base on contraceptive method choice, it remains uncertain which factors are most influential in predisposing women toward certain methods and against others. This paper addresses this gap in knowledge by making use of rarely-measured perceptions about specific methods, perceived social network experience of methods, and women's own past experiences using specific methods. We draw on baseline data from the project, "Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning." Using conditional logit analysis, we ascertain which perceived method-specific attributes, including past experience of methods by women themselves and by their friends, predict preferred future contraceptive method among 317 women living in Nairobi slums who are using no method but intend to start in the next 12 months. Results show that satisfaction with past use, positive experience of use by a woman's social network, husband/partner's approval, lack of interference with menses, and perception of safety for long term use were all associated with choice of a future method.

Women's attitudes and beliefs towards specific contraceptive methods in Bangladesh and Kenya.

BACKGROUND: Missing from the huge literature on women's attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants). METHODS: In each site, 2424 to 2812 married women aged 15-39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study. RESULTS: While current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower. CONCLUSIONS: High levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.

Unintended Childbearing and Child Growth in Northern Malawi.

Objective The study aims to assess whether unintended children experience slower growth than intended children. Methods We analysed longitudinal data linked to the Karonga Health and Demographic Surveillance Site collected over three rounds between 2008 and 2011 on women's fertility intentions and anthropometric data of children. Using the prospective information on fertility intention we assessed whether unintended children are more likely to be stunted than intended children. We applied Propensity Score Matching technique to control for endogenous factors affecting both the probability that a family has an unwanted birth and a child with poor health outcomes. Results We found that 24 % of children from unwanted pregnancies were stunted compared with 18 % of mistimed pregnancies and 17 % of those from wanted pregnancies. However, these differences in probability of children being stunted, though in the expected direction, were not significant either for large or small families, after controlling for age. The number of children in the household was associated with stunting and boys were substantially more likely to be stunted than girls. Conclusion We found no significance difference in probability of being stunted by mother's fertility intention.

Reasons for unmet need for family planning, with attention to the measurement of fertility preferences: protocol for a multi-site cohort study.

BACKGROUND: Unmet need for family planning points to the gap between women's reproductive desire to avoid pregnancy and contraceptive behaviour. An estimated 222 million women in low- and middle-income countries have unmet need for modern contraception. Despite its prevalence, there has been little rigorous research during the past fifteen years on reasons for this widespread failure to implement childbearing desires in contraceptive practice. There is demographic survey data on women's self-reported reasons for non-use, but these data provide limited insight on the full set of possible obstacles to use, and one may doubt the meaningfulness of explanations provided by non-users alone. To rectify this evidence gap, this study will gather extensive information on women's perceptions of contraception (generic and method-specific) and their past contraceptive experience, and it will allow for more complexity in fertility preferences than is standard in demographic surveys. METHODS: A multi-site cohort study will be conducted in urban Kenya, rural Kenya, and rural Bangladesh. In each setting trained fieldworkers will recruit and interview 2600 women, with participants re-interviewed at 12 and 18 months. Data will be collected using a questionnaire whose development was informed by a review of existing literature and instruments from past studies in both developed and developing countries. Dozens of experts in the field were consulted as the instrument was developed. The questionnaire has three main components: a sub-set of Demographic and Health Survey items measuring socio-demographic characteristics, reproductive history, and sexual activity; additional questions on prospective and retrospective fertility preferences designed to capture ambivalence and uncertainty; and two large blocks of items on (i) generic concerns about contraception and (ii) method-specific attributes. The method-specific items encompass eight modern and traditional methods. DISCUSSION: Policy and programmes intended to reduce unmet need for contraception in developing countries should be informed by clear understanding of the causes of this phenomenon to better reflect the population needs and to more effectively target planning and investments. To this end, this study will field an innovative instrument in Kenya and Bangladesh. The information to be collected will support a rigorous assessment of reasons for unmet need for family planning.

Effect of a mobile phone-based intervention on post-abortion contraception: a randomized controlled trial in Cambodia.

OBJECTIVE: To assess the effect of a mobile phone-based intervention (mHealth) on post-abortion contraception use by women in Cambodia. METHODS: The Mobile Technology for Improved Family Planning (MOTIF) study involved women who sought safe abortion services at four Marie Stopes International clinics in Cambodia. We randomly allocated 249 women to a mobile phone-based intervention, which comprised six automated, interactive voice messages with counsellor phone support, as required, whereas 251 women were allocated to a control group receiving standard care. The primary outcome was the self-reported use of an effective contraceptive method, 4 and 12 months after an abortion. FINDINGS: Data on effective contraceptive use were available for 431 (86%) participants at 4 months and 328 (66%) at 12 months. Significantly more women in the intervention than the control group reported effective contraception use at 4 months (64% versus 46%, respectively; relative risk, RR: 1.39; 95% confidence interval, CI: 1.17-1.66) but not at 12 months (50% versus 43%, respectively; RR: 1.16; 95% CI: 0.92-1.47). However, significantly more women in the intervention group reported using a long-acting contraceptive method at both follow-up times. There was no significant difference between the groups in repeat pregnancies or abortions at 4 or 12 months. CONCLUSION: Adding a mobile phone-based intervention to abortion care services in Cambodia had a short-term effect on the overall use of any effective contraception, while the use of long-acting contraceptive methods lasted throughout the study period.

Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women in Nairobi's Urban Slums.

Unmet need for contraception is highest within 12 months post-delivery, according to research. Using longitudinal data from the Nairobi Urban Health and Demographic Surveillance System, we assess the dynamics of contraceptive use during the postpartum period among women in Nairobi's slums. Results show that by 6 months postpartum, 83 percent of women had resumed sexual activity and 51 percent had resumed menses, yet only 49 percent had adopted a modern contraceptive method. Furthermore, almost half of women discontinued a modern method within 12 months of initiating use, with many likely to switch to another short-term method with high method-related dissatisfaction. Women who adopted a method after resumption of menses had higher discontinuation rates, though the effect was much reduced after adjusting for other variables. To reduce unmet need, effective intervention programs are essential to lower high levels of discontinuation and encourage switching to more effective methods.

Individual, partner, and community variables associated with method-specific contraceptive beliefs in urban and rural Kenya.

OBJECTIVES: Global unmet need for contraception remains high. Contraceptive health-related beliefs are a barrier to contraceptive use but are poorly understood. This study examined quantitative differences in two health-related beliefs between pills, injectables, and implants. STUDY DESIGN: We used cross-sectional baseline data collected between August and December 2016 from Nairobi (urban) and Homa Bay (rural) Kenya among women aged 15 to 39 years (N = 5081). Dichotomous outcome variables were constructed for two health-related beliefs (infertility and serious health problems) for the three methods. Using a socioecological framework, possible risk factors at individual, relationship, and community levels were identified a priori. We used logistic regression to identify factors associated with method-specific beliefs. RESULTS: Roughly a quarter of participants believed the methods caused serious health problems, while a smaller overall proportion believed the methods caused infertility. Risk factors patterned similarly across methods but differed between beliefs. In adjusted models, perceived partner approval of a method was associated with lower odds of believing it caused infertility or serious health problems. Unsatisfactory or mixed social network experiences predicted serious health problems but not infertility beliefs. Current use was associated with lower odds of believing all three methods caused serious health problems, but only implant users were more likely to believe they caused infertility. Past use was associated with higher odds of serious health problems but not infertility beliefs. CONCLUSIONS: Across three methods, negative community and perceived partner attitudes toward specific contraceptive methods were associated with higher individual-level odds of contraceptive health beliefs in Kenya. IMPLICATIONS: Efforts to support women who want to use contraception should focus on providing information on contraceptive health and fertility concerns, ideally targeting partners and women of all ages in addition to potential contraceptive users. It is reasonable to address these concerns broadly across commonly used contraceptive methods.

Women's beliefs about methods and contraceptive discontinuation: Results from a prospective study from Nairobi and Homa Bay counties in Kenya.

Background: Rates of contraceptive discontinuation are high in many low and middle countries contributing to unmet need for contraception and other adverse reproductive health outcomes. Few studies have investigated how women's beliefs about methods and strength of fertility preferences affect discontinuation rates. This study examines this question using primary data collected in Nairobi and Homa Bay counties in Kenya. Methods: We used data from two rounds of a longitudinal study of married women ages 15-39 years (2,812 and 2,424 women from Nairobi and Homa Bay respectively at round 1). Information on fertility preferences, past and current contraceptive behavior, and method-related beliefs about six modern contraceptive methods were collected, along with a monthly calendar of contraceptive use between the two interviews. The analysis focused on discontinuation of the two most commonly used methods in both sites, injectables and implants. We carry out competing risk survival analysis to identify which method related beliefs predict discontinuation among women using at the first round. Results: The percentages of episodes discontinued in the 12 months between the two rounds was 36%, with a higher rate of discontinuation in Homa Bay (43%) than in the Nairobi slums (32%) and higher for injectables than implants. Method related concerns and side effects were the major self-reported reasons for discontinuation in both sites. The competing risk survival analysis showed that the probability of method related discontinuation of implants and injectables was significantly lower among respondents who believed that the methods do not cause serious health problems (SHR = 0.78, 95% CI: 0.62-0.98), do not interfere with regular menses (SHR = 0.76, 95% CI: 0.61-0.95) and do not cause unpleasant side effects (SHR = 0.72, 95% CI 0.56-0.89). By contrast, there were no net effects of three method related beliefs that are commonly cited as obstacles to contraceptive use in African societies: safety for long-term use, ability to have children after stopping the method, and the approval of the husband. Conclusion: This study is unique in its examination of the effect of method-specific beliefs on subsequent discontinuation for a method-related reason, using a longitudinal design. The single most important result is that concerns about serious health problems, which are largely unjustified and only moderately associated with beliefs about side effects, are a significant influence on discontinuation. The negative results for other beliefs show that the determinants of discontinuation differ from the determinants of method adoption and method choice.

Method-specific beliefs and subsequent contraceptive method choice: Results from a longitudinal study in urban and rural Kenya.

INTRODUCTION: Evidence from sub-Saharan Africa, including Kenya, shows that negative beliefs about contraceptive methods are associated with non-use. However, little is known about the relationship between contraceptive beliefs and subsequent method choice. METHODOLOGY: We used data from a two-year longitudinal survey of married women aged 15-39 years at enrollment from one urban site (Nairobi) and one rural site (Homa Bay) in Kenya. Analysis entails descriptive statistics and estimation of a conditional logit analysis to examine associations between method-specific beliefs and choice of injectables, implants or pills among women who were not using any method or were pregnant at baseline (round 1) but adopted these methods at 12-month follow-up (Nairobi, n = 221; Homa Bay n = 197). RESULTS: Beliefs about pills, injectables and implants among non-users were generally negative. With the partial exception of the pill in Nairobi, the majority thought that each method was likely to cause serious health problems, unpleasant side effects, menstrual disruption, and would be unsafe for long-term use. In both sites, satisfied past use of a method and the perception that a method is easy to use had a major influence on method choice. Concerns about menstrual disruption and safety for long-term use were unimportant in both sites. There were some marked differences between the two sites. Beliefs about long-term fertility impairment and perceived husband approval had strong influences on choice of injectables, implants or pills in the urban site but not in the rural site. CONCLUSION: The relative importance of beliefs, some erroneous, in predisposing women to choose one method over another appears to be conditioned by the social context. There is need for family planning counseling programmes to pay attention to erroneous beliefs and misconceptions about contraceptives.

Which contraceptive side effects matter most? Evidence from current and past users of injectables and implants in Western Kenya.

OBJECTIVES: The objectives were to assess experiences of menstrual bleeding and nonbleeding side effects among current and past users of injectables and implants and the associations between side effects and method evaluations by women - satisfaction, perceived suitability, the likelihood of future use and intended duration of use. STUDY DESIGN: We used data on past and current users of injectables and implants from a survey of 1866 married or cohabiting women who participated in the third round of a 2-year prospective longitudinal study conducted in Homa Bay County, Western Kenya. Descriptive and bivariate analysis with χ2 tests was used to assess statistically significant associations between experience of bleeding/nonbleeding side effects and method-specific attitudes. RESULTS: Self-reported method-related bleeding problems were high among current and past users of injectables (range 69%-79%) and implants (range 55%-60%) and much more common than nonbleeding side effects. For both methods, experience of either bleeding or nonbleeding side effects reduces positive evaluations, but the conjunction of both types had particularly pronounced consequences. Heavy bleeding was more strongly related to method evaluation (satisfaction and the likelihood of future use; p < .001) among past users than other forms of menstrual bleeding disorders. Even among current users, about one third regarded bleeding side effects as very serious. Care-seeking from a healthcare provider for management of contraceptive-related side effects was low among current users (less than 40%) and modest among past users (range 53%-63%). CONCLUSIONS: The results underscore the need to strengthen programs on counseling and information on contraceptive side effects including menstrual bleeding disturbances to improve method satisfaction and reduce discontinuation. IMPLICATION: The experience of contraceptive-related menstrual bleeding and nonbleeding side effects reduces positive evaluation of the method and deters past users from future use of the method.

Changes in, and factors associated with, frequency of sex in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles (Natsal).

OBJECTIVES: To examine changes over time in the reported frequency of occurrence of sex and associations between sexual frequency and selected variables. DESIGN: Repeat, cross sectional, population based National Surveys of Sexual Attitudes and Lifestyles (Natsal-1, Natsal-2, and Natsal-3). SETTING: British general population. PARTICIPANTS: 18 876 men and women aged 16-59 and resident in Britain were interviewed in Natsal-1, completed in 1991; 11 161 aged 16-44 years in Natsal-2, completed in 2001, and 15 162 aged 16-74 years in Natsal-3, completed in 2012. Comparisons of actual and preferred sexual frequency in men and women aged 16-44 (the age range common to all surveys) between the three surveys. Factors associated with sexual frequency of at least once a week were examined using Natsal-3 data. MAIN OUTCOME MEASURES: Sexual activity in the past month; frequency of sex in the past month; preferred frequency of sex. RESULTS: Median number of occasions of sex in the past month was four in Natsal-1 and Natsal-2 and three in Natsal-3 among women; and three in Natsal-1, Natsal-2, and Natsal-3 among men. The proportion reporting no sex in the past month fell between Natsal-1 and Natsal-2 (from 28.5% to 23.0% in women and from 30.9% to 26.0% in men) but increased significantly in Natsal-3 (to 29.3% in women and 29.2% in men). The proportion reporting sex 10 times or more in the past month increased between Natsal-1 and Natsal-2, from 18.4% to 20.6% in women and from 19.9% to 20.2% in men, but fell in Natsal-3, to 13.2% in woman and 14.4% in men. Participants aged 25 and over, and those married or cohabiting, experienced the steepest declines in sexual frequency (P values for interaction <0.05). Alongside the declines in sexual frequency, there was an increase in the proportion reporting that they would prefer sex more often. Age adjusted odds ratios showed that men and women in better physical and mental health had sex more frequently, as did those who were fully employed and those with higher earnings. CONCLUSIONS: Frequency of sex has declined recently in Britain, more markedly among those in early middle age and those who are married or cohabiting. The findings and their implications need to be explained in the context of technological, demographic, and social change in Britain and warrant further investigation.

Experiences of romantic relationships and desires to marry and have children among youth in a low-fertility society.

Introduction: This study aims to explore experiences of romantic relationships and to examine determinants of desires to marry and have children in the future among Japanese university students. Methods: A cross-sectional study was conducted among undergraduate students of A University, located in the capital city of a Japanese prefecture, using an anonymous self-administered and structured questionnaire developed by an online survey software. Results: A total of 815 respondents with complete data were analyzed by logistic regression analysis. Over 80% of males and females expressed the desire to marry and have children in the future. It was found that for both female and male respondents, the "desire to marry" was associated with currently being in a romantic relationship or having experience of sexual intercourse. On the contrary, the "desire to have children" was associated with currently being in a romantic relationship or having experience of sexual intercourse only among male respondents, and no significant association was observed among female respondents. Conclusion: "Currently being in a romantic relationship" and "having experience of sexual intercourse" were associated with wanting to marry and have children in the future among male university students. This suggests that these may be important factors in providing a positive perception regarding having children when they attain childbearing age.

Factors influencing the likelihood of acceptance of postpartum intrauterine devices across four countries: India, Nepal, Sri Lanka, and Tanzania.

OBJECTIVE: To examine the factors that positively influenced the likelihood of accepting provision of postpartum intrauterine devices (PPIUDs) across four countries: Sri Lanka, Nepal, Tanzania, and India. METHODS: Healthcare providers were trained across 24 facilities in counselling and insertion of PPIUDs as part of a large multicountry study. Women delivered were asked to take part in a 15-minute face-to-face structured interview conducted by in-country data collection officers prior to discharge. Univariate analysis was performed to investigate factors associated with acceptance. RESULTS: From January 2016 to November 2017, 6477 health providers were trained, 239 033 deliveries occurred, and 219 242 interviews were conducted. Of those interviewed, 68% were counselled on family planning and 56% on PPIUD, with 20% consenting to PPIUD. Multiple counselling sessions was the only factor resulting in higher consent rates (OR 1.30-1.39) across all countries. Odds ratios for women's age, parity, and cadre of provider counselling varied between countries. CONCLUSION: Consent for contraception, specifically PPIUD, is such a culturally specific topic and generalization across countries is not possible. When planning contraceptive policy changes, it is important to have an understanding of the sociocultural factors at play.