Estimating infertility prevalence in low-to-middle-income countries: an application of a current duration approach to Demographic and Health Survey data.

STUDY QUESTION: Can infertility prevalence be estimated using a current duration (CD) approach when applied to nationally representative Demographic and Health Survey (DHS) data collected routinely in low- or middle-income countries? SUMMARY ANSWER: Our analysis suggests that a CD approach applied to DHS data from Nigeria provides infertility prevalence estimates comparable to other smaller studies in the same region. WHAT IS KNOWN ALREADY: Despite associations with serious negative health, social and economic outcomes, infertility in developing countries is a marginalized issue in sexual and reproductive health. Obtaining reliable, nationally representative prevalence estimates is critical to address the issue, but methodological and resource challenges have impeded this goal. STUDY DESIGN, SIZE, DURATION: This cross-sectional study was based on standard information available in the DHS core questionnaire and data sets, which are collected routinely among participating low-to-middle-income countries. Our research question was examined among women participating in the 2013 Nigeria DHS (n = 38 948). Among women eligible for the study, 98% were interviewed. PARTICIPANTS/MATERIALS, SETTING, METHODS: We applied a CD approach (i.e. current length of time-at-risk of pregnancy) to estimate time-to-pregnancy (TTP) and 12-month infertility prevalence among women 'at risk' of pregnancy at the time of interview (n = 7063). Women who were 18-44 years old, married or cohabitating, sexually active within the past 4 weeks and not currently using contraception (and had not been sterilized) were included in the analysis. Estimates were based on parametric survival methods using bootstrap methods (500 bootstrap replicates) to obtain 95% CIs. MAIN RESULTS AND THE ROLE OF CHANCE: The estimated median TTP among couples at risk of pregnancy was 5.1 months (95% CI: 4.2-6.3). The estimated percentage of infertile couples was 31.1% (95% CI: 27.9-34.7%)-consistent with other smaller studies from Nigeria. Primary infertility (17.4%, 95% CI: 12.9-23.8%) was substantially lower than secondary infertility (34.1%, 95% CI: 30.3-39.3%) in this population. Overall estimates for TTP >24 or >36 months dropped to 17.7% (95% CI: 15.7-20%) and 11.5% (95% CI: 10.2-13%), respectively. Subgroup analyses showed that estimates varied by age, coital frequency and fertility intentions, while being in a polygynous relationship showed minimal impact. LIMITATIONS, REASONS FOR CAUTION: The CD approach may be limited by assumptions on when exposure to risk of pregnancy began and methodologic assumptions required for estimation, which may be less accurate for particular subgroups or populations. Unrecognized pregnancies may have also biased our findings; however, we attempted to address this in our exclusion criteria. Limiting to married/cohabiting couples may have excluded women who are no longer in a relationship after being blamed for infertility. Although probably rare in this setting, we lack information on couples undergoing infertility treatment. Like other TTP measurement approaches, pregnancies resulting from contraceptive failure are not included, which may bias estimates. WIDER IMPLICATIONS OF THE FINDINGS: Nationally representative estimates of TTP and infertility based on a clinical definition of 12 months have been limited within developing countries. This approach represents a pragmatic advance in our ability to measure and monitor infertility in the developing world, with potentially far-reaching implications for policies and programs intended to address reproductive health. STUDY FUNDING/COMPETING INTERESTS: There are no competing interests and no financial support was provided for this study. Financial support for Open Access publication was provided by the World Health Organization.

Primary Care Patients' Willingness to Participate in Comprehensive Weight Loss Programs: From the WWAMI Region Practice and Research Network.

PURPOSE: In the United States, 69% of adults are overweight or obese, as defined by a body mass index (BMI) ≥25 kg/m(2). The US Preventive Services Task Force recommends screening all adult patients for obesity and referring obese patients to intensive, multicomponent behavioral weight loss programs comprising 12 to 26 yearly sessions. The objective of this study is to determine the degree to which overweight and obese primary care patients report willingness to participate in these intensive weight loss programs and to identify the patient factors associated with reported willingness to participate. METHODS: This 2013 cross-sectional survey was offered to all adult patients seen for an office visit at 1 of 12 primary care clinics in the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) Region Practice and Research Network (WPRN). Patients self-reported both their health information and their willingness to participate in a comprehensive weight loss program. Respondents were characterized by descriptive statistics. We compared reported rates of willingness to participate by patient factors and assessed which patient factors were independently associated with reported willingness using bivariate analysis and logistic regression, respectively. RESULTS: Of overweight and obese respondents, 63% reported willingness to participate in comprehensive weight loss programs. Age, sex, race/ethnicity, insurance status, BMI, and reason for wanting to lose weight were all significantly and independently associated with reported willingness to participate. CONCLUSIONS: Reported willingness to participate in comprehensive weight loss programs suggests that additional resources are needed to understand strategies for disseminating and implementing effective comprehensive weight loss programs.

Unintended pregnancy risk and contraceptive use among women 45-50 years old: Massachusetts, 2006, 2008, and 2010.

BACKGROUND: Little is known about unintended pregnancy risk and current contraceptive use among women ≥45 years old in the United States. OBJECTIVES: The purpose of this study was to describe the prevalence of women ages 45-50 years old at risk for unintended pregnancy and their current contraceptive use, and to compare these findings to those of women in younger age groups. STUDY DESIGN: We analyzed 2006, 2008, and 2010 Massachusetts Behavioral Risk Factor Surveillance System data, the only state in the United States to collect contraceptive data routinely from women >44 years old. Women 18-50 years old (n = 4930) were considered to be at risk for unintended pregnancy unless they reported current pregnancy, hysterectomy, not being sexually active in the past year, having a same-sex partner, or wanting to become pregnant. Among women who were considered to be at risk (n = 3605), we estimated the prevalence of current contraceptive use by age group. Among women who were considered to be at risk and who were 45-50 years old (n = 940), we examined characteristics that were associated with current method use. Analyses were conducted on weighted data using SAS-callable SUDAAN (RTI International, Research Triangle Park, NC). RESULTS: Among women who were 45-50 years old, 77.6% were at risk for unintended pregnancy, which was similar to other age groups. As age increased, hormonal contraceptive use (shots, pills, patch, or ring) decreased, and permanent contraception (tubal ligation or vasectomy) increased as did non-use of contraception. Of women who were 45-50 years old and at risk for unintended pregnancy, 66.9% reported using some contraceptive method; permanent contraception was the leading method reported by 44.0% and contraceptive non-use was reported by 16.8%. CONCLUSION: A substantial proportion of women who were 45-50 years old were considered to be at risk for unintended pregnancy. Permanent contraception was most commonly used by women in this age group. Compared with other age groups, more women who were 45-50 years old were not using any contraception. Population-based surveillance efforts are needed to follow trends among this age group and better meet their family planning needs. Although expanding surveillance systems to include women through 50 years old requires additional resources, fertility trends that show increasingly delayed childbearing, uncertain end of fecundity, and potential adverse consequences of unplanned pregnancy in older age may justify these expenditures.