Obesity and cholecystectomy among women: implications for prevention.

Almost all studies of the association of body mass with the risk of gallbladder disease have found that risk increases with obesity. Some studies report a nonlinear relationship of body mass to gallbladder disease risk, and some report that the association of excess body mass with increased risk of gallbladder disease is confined to younger women. We examined the association of body mass with the risk of cholecystectomy based on data from 14 years of follow-up of 16,638 women. The cholecystectomy rate was much greater in the highest quintile of Quetelet's body mass index than in other quintiles. The striking association of high rates of cholecystectomy with the highest quintile of Quetelet's body mass index was observed in each age group studied. The low incidence of cholecystectomy in young, thin women made the relative risk of cholecystectomy in women in the fifth quintile of body mass highest in women under 25 years of age. The observation that cholecystectomy rates are not linearly associated with obesity suggests that women in the highest quintiles of body mass could be considered a reasonable group in which strategies for prevention of gallbladder disease might be tested.

PIP: The Walnut Creek Contraceptive Drug Study which began in 1968 and ended in 1972, monitored 16,638 women as part of a multiphasic health checkup and collected information on oral contraceptive (OC) use; smoking, alcohol use; other habits, and family and medical histories. The number of women years was determined in each age and weight category. The rates of gallbladder disease were similarly calculated. The Cox proportional hazards model was utilized as implemented in the multivariate life table analyses. In addition, Quetelet's body mass index as a measure of obesity was applied. 16,240 women had an intact gallbladder; of these 432 were hospitalized with diagnosis of gallbladder disease. The diagnosis was confirmed in 423 women: 98% had cholelithiasis accompanied by pathologic evidence of cholecystitis. The gallbladder disease rate increased with age, with body mass index, and it was dramatically higher in women in the highest quintile of Quetelet's body mass index than in other quintiles at all ages. A nonlinear association of cholecystectomy with obesity persisted. At least 500,000 cholecystectomies are carried out in the US annually, and the risk is much higher in women in the uppermost quintile, thus it is reasonable to suggest that preventive efforts should focus on this group.

Gender differences in AIDS-relevant condom attitudes and condom use.

Two studies, conducted approximately one year apart, examined gender differences in AIDS-relevant condom attitudes, condom use behaviors, and relationships among attitudes and condom use behaviors. Subjects (N = 248, N = 528) were undergraduates, primarily heterosexual. Females reported more favorable attitudes, with the exception of greater inhibition about buying and possessing condoms. Men engaged in preliminary condom use behaviors (carrying and keeping condoms at home) substantially more often than did women. Preliminary condom use behaviors predicted past and intended condom use more consistently for men than for women. Relationships between condom attitudes and condom use behaviors were generally similar for both sexes, with poorer self-control explaining the most variance in past and intended condom use. These results, interpreted from the perspective of Eagly's (1987) gender role theory, suggest that although females may indirectly influence condom use decisions, providing condoms is the expected role of males, infusing them with greater control over the interpersonal process.

PIP: 2 studies were conducted 1 year apart exploring gender differences in AIDS-relevant condom attitudes, condom use behaviors, and relationships among attitudes and condom use behaviors. 248 self-reported heterosexual undergraduates were studied in the 1st study. Participants were 65% female, 96% self-reported heterosexuals, 87% white, and of average age 22.77 years. 71% reported having sexual intercourse at least once in the preceding 2 years and 64% reported using a condom at least once during sex in the preceding 2 years. The 2nd group of 528 individuals sampled in the 2nd study had characteristics which were highly similar to those of the 1st study, except that 74% of the participant were female. Females generally had more favorable attitudes than men about condoms, but were more inhibited than men about buying and possessing them. Men carried and kept condoms at home far more often than did women. This behavior predicted past and intended condom use more consistently for men than for women. Generally similar relationships were found for both sexes between condom attitudes and condom use behaviors; poorer self-control explained the most variance in past and intended condom use. The results suggest that while females may indirectly influence condom use decisions, providing condoms is the expected role of males. Interventions with the objective of increasing the use of condoms during sexual intercourse should be designed accordingly.

The use of modern and traditional methods of fertility control in Bangladesh: a multivariate analysis.

An attempt has been made to study the use pattern of traditional and modern methods of fertility control among currently married women of reproductive ages utilizing the 1989 BFS data. Bivariate analysis has been employed to study the differentials in the use pattern by some selected demographic and socio-economic characteristics. Also, multivariate logistic regression analysis has been used to identify independent contributions of each selected covariate. It has been observed, however, that there is universality of knowledge about contraceptive methods. Of the total 31 percent, about 23 percent were using modern methods and the rest, 8 percent, traditional methods. Analysis using a logistic regression model showed that visits of family planning workers have very strong and positive influence on the current use of modern contraceptives as compared to traditional methods. Duration of effective marriage also emerged as a strong determinant of modern versus traditional methods use but it influenced modern methods use negatively. Also, administrative division is an important variable. Residents of Rajshahi division were significantly more (relative odds of 2.5) likely to be using modern methods than residents of Chittagong division. The likelihood of women having electricity in their household of being a current user of modern contraceptives is almost 2 times higher compared to women without electricity in their households. Education and occupation of husbands also exerts effect on current use of modern contraceptives. The odds of current use of modern methods among women whose husbands have secondary and higher level of education is one-and-a-half times higher than that of women with husbands having no formal education. However, wives of landowners were less (relative odds of 0.72) likely to use these methods as compared to traditional methods than wives of labourers or farmers. The probability of current use of modern contraceptives was higher (relative odds of 1.5) among women who discussed family planning with their husbands than those who did not.

PIP: The use pattern of traditional and modern methods of fertility control was studied among currently married women of reproductive age utilizing the data extracted from the 1989 Bangladesh Fertility Survey (BFS) conducted during December 1988 to April 1989. This national two-stage probability sample survey selected 175 rural and 100 urban clusters. At the second stage, from 11,236 households (7984 rural and 3252 urban) a total of 11,906 ever-married women under 50 years old (8467 rural and 3439 urban) were successfully interviewed, constituting the reference population. Bivariate analysis studied the differentials in the use pattern by some selected demographic and socioeconomic characteristics. Also, multivariate logistic regression analysis was used to identify independent contributions of each selected covariate. There was universal knowledge about contraceptive methods. The contraceptive prevalence rate amounted to 31%; 23% were using modern methods and 8% relied on traditional methods. Logistic regression showed that visits of family planning workers had very strong positive influence on the current use of modern contraceptives as compared to traditional methods. Duration of marriage influenced modern method use negatively. Residents of Rajshahi division were significantly more likely (relative odds of 2.5) to use modern methods than residents of Chittagong division. Women having electricity in their household were almost 2 times more likely to be current users of modern contraceptives compared to women without electricity. Non-Muslim women were significantly less likely to use modern contraceptives (relative odds of 0.5) compared to Muslim women. Women whose husbands had secondary and higher levels of education were 1.5 times more likely to use modern methods than women whose husbands lacked education. However, wives of landowners were less likely (relative odds of 0.72) to use modern methods vs. traditional methods than wives of laborers or farmers. Women who discussed family planning with their husbands tended to use modern contraceptives more (relative odds of 1.5) than those who did not.

Oral contraceptives and pregnancy in relation to peptic ulcer.

There is evidence in the scientific literature that peptic ulceration occurs less frequently during pregnancy than at other times. This encouraged us to examine the pattern of hospitalisation for peptic ulcer in the Oxford-Family Planning Association contraceptive study. In total, 175 women in the study had been hospitalised for peptic ulcer; 105 had duodenal disease, 55 had gastric disease and 22 had disease of unspecified site (some had disease at more than one location). Hospitalisation for peptic ulcer increased with age, parity and cigarette smoking. In addition, hospitalisation was at a low rate during pregnancy and was not seen at all during the 12 months following delivery. There was no relationship between hospitalisation for peptic ulcer and total duration of oral contraceptive use. Likewise, there was no significant relationship with recency of oral contraceptive use, but the lowest rate of hospitalisation was in current users of the pill.

PIP: Researchers analyzed data from the Oxford-Family Planning Association contraceptive study on 175 women hospitalized for peptic ulcer in England or Scotland to determine whether an association existed between oral contraceptive (OC) use and peptic ulcers and pregnancy and peptic ulcers. Hospitalization for peptic ulcer increased consistently with age (peptic ulcer hospitalization rate for ages 25-29 years vs. 50+ years was .3 total women years [TWY] vs. .84; p = .006). It also rose steadily with the number of cigarettes smoked/day (0.51 TWY for never smoked vs. 0.89 TWY for 15+; P = .001). It was positively associated with parity (0.6 TWY for nulliparity vs. 0.8 TWY for =or 3 children; p = .04), but parity off 1-2 appeared to have somewhat of a protective effect (0.55 TWY). Pregnant women were less likely to experience a peptic ulcer than never pregnant women (0.29 TWY vs. 0.67 TWY), but the difference was not significant. None of the once-pregnant women who had been pregnant within the last 12 months were hospitalized for peptic ulcer. Neither duration nor recency of OC use had a protective effect against peptic ulcer. Yet, current OC users did have a lower hospitalization rate for peptic ulcer than non-OC users (0.42 TWY vs. 0.68 TWY). Therefore OCs may indeed have some protective effect, but researchers must carefully design a study with a large sample size to detect any possible protective effect.

The reliability of surrogate information about oral contraceptive use, smoking, height and weight collected from men about their wives.

Ninety-nine female hospital patients and their husbands were asked to complete separate questionnaires about the woman's history of using oral contraceptives as well as her height, weight and cigarette smoking habits. The questionnaires were completed in the presence of a research nurse to ensure that there was no discussion. Reports of height, weight and smoking status showed a good agreement between the women and their husbands. Husbands usually reported accurately on whether the woman was a current or past user of oral contraceptives, but most of them were unable to name the brand of oral contraceptive that was used, or give an estimate of the duration of use.

PIP: 99 female hospital patients and their husbands were asked to complete separate questionnaires about the woman's history of using oral contraceptives as well as her height, weight and cigarette smoking habits. The questionnaires were completed in the presence of a research nurse to ensure that there was no discussion. Reports of height, weight and smoking status showed a good agreement between the women and their husbands. Husbands usually reported accurately on whether the woman was a current or past user of oral contraceptives, but most of them were unable to name the brand of oral contraceptive that was used, or give an estimate of the duration of use. The participants were currently married woman aged between 20 and 40 years admitted to the Royal Berkshire Hospital in Reading, England, between September 1987 and April 1988, who were suffering from conditions not known to be connected in any way with contraceptive method.

A longitudinal study of birth control and pregnancy outcome among women in a Swedish population.

The prevalence of contraception and pregnancy outcome in the same women, at 19, 24, and 29 years of age, was assessed in a longitudinal cohort study using a postal questionnaire technique. A one-in-four random sample of all women born in 1962 and resident in the city of Göteborg in 1981, was obtained from the population register (n = 656). Respondents from 1981 were re-assessed in 1986 and 1991. Four hundred thirty women (66%) answered the questionnaire on all three occasions and are included in the analysis. Contraceptive usage was as follows (at 19, 24, and 29 years of age, respectively): oral contraception (OC) 47%/51%/22%; intrauterine device 3%/11%/19%; barrier methods 12%/12%/20%; depot gestagen 0/0.2%/0.4%; no contraception 39%/26%/25%. OCs had been taken at some time by 93%. Reasons give for cessation of OC were: contraception not required 10%/21%/20%; fear of OC 28%/32%/35%; menstrual disorder 17%/13%/14%; weight increase 20%/16%/15%; mental side effects 14%/ 21%/20%; desire to become pregnant 7%/33%/52%. Pregnancy outcome was as follows: Ever pregnant 17%/42%/ 71%; children 5% had 1-2 children/27% had 1-3 children/ 59% had 1-5 children; 12%/25%/30% > or = 1 legal abortion; 3%/8%/15% > or = 1 miscarriage; and > or = 1 ectopic pregnancy 0.2%/1.2%/2.1%. On all three survey occasions, more than 97% of the legal abortions were performed < or = 12 weeks gestation. The complication rate following legal abortion was 7%. The proportion of live births to the total number of pregnancies was 25%, 45%, and 61%. The relationship between method of contraception, history of pregnancy, legal abortion, and smoking habits was analyzed in detail. Despite the availability of effective contraception, the ratio of legal abortions to live births was high. Fear of side effects was the commonest reason for discontinuing OC.

PIP: Contraceptive use patterns and pregnancy outcomes were assessed in a longitudinal cohort study of 656 women (a 1-in-4 random sample) born in 1962 and residing in Goteborg, Sweden, in 1981. Included in the present analysis were the 430 women (66%) who returned all three postal questionnaires (1981 at age 19 years, 1986 at 24 years, and 1991 at 29 years). Contraception had been used at some point by 73% of women at age 19, 94% at age 24, and 97% at age 29. Contraceptive usage, by method, at ages 19, 24, and 29 years, respectively, was as follows: oral contraceptives (OCs) 47%, 51%, and 22%; IUD 3%, 11%, and 19%; barrier methods 12%, 12%, and 20%; depot gestagen 0, 0.2%, and 0.4%; and no method 39%, 26%, and 25%. 93% of respondents had taken OCs at some time in the 10-year study period; the major reasons for discontinuation were fear of side effects, menstrual disorders, weight gain, and mental side effects. Pregnancy outcomes at ages 19, 24, and 29 years, respectively, were as follows: ever pregnant 17%, 42%, and 71%; live births 5%, 27%, and 59%; 1 or more legal abortions 12%, 25%, and 30%; 1 or more spontaneous abortions 3%, 8%, and 15%; and 1 or more ectopic pregnancies 0.2%, 1.2%, and 2.1%. The proportion of live births to the total number of pregnancies was 25% at age 19 years, 45% at age 24 years, and 61% at age 29 years. The shifts in contraceptive use patterns over the 10-year study period reflect both improvements in available contraceptive technologies and changes in women's life situation with increasing age and parity.

Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation.

The contraceptive efficacy of oral contraceptives (OCs) depends on their proper and continued use, particularly with lower estrogen preparations. However, few studies have examined why women miss pills or discontinue OCs, and those that do tend to be small and to focus on adolescents. To address the issues of poor OC compliance and early OC discontinuation, we analyzed OC use in a convenience sample of 6,676 women between the ages of 16 and 30 from Denmark, France, Italy, Portugal, and the United Kingdom. Logistic regression was used to examine the independent effect of each factor. Poor compliance was associated with a lack of established routine for pill-taking (relative risk [RR] = 3.3), failure to read and understand written materials that came with the OC package (RR = 2.2), not receiving adequate information or help about OCs from their health care provider (RR = 1.5), and occurrence of certain side effects, including hirsutism (RR = 2.1), nausea (RR = 1.4), bleeding irregularities (RR = 1.3), and breast tenderness (RR = 1.2). Women who were inconsistent OC users, missing one or more pills per cycle, were almost three times as likely to experience an unintended pregnancy while using OCs than were women who took their OCs consistently. Factors that predicted early discontinuation (women who wished to continue contraceptive protection but discontinued OC use) were primarily side effects, including nausea (RR = 2.1), bleeding (RR = 1.9), breast tenderness (RR = 1.8), mood changes (RR = 1.8), and weight gain (RR = 1.4).(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: To address the issues of poor oral contraceptive (OC) compliance and early OC discontinuation, OC use was analyzed in a convenience sample of 6676 women between the ages of 16 and 30 from Denmark, France, Italy, Portugal, and the United Kingdom, obtained from the Wyeth-Ayerst Contraceptive survey conducted in 1993. Logistic regression was used to examine the independent effect of each factor. 81% of the women used their OCs consistently. User characteristics accounted for inconsistent use. Poor compliance was associated with a lack of established routine for pill-taking and failure to read and understand written materials that came with the OC package. Those who understood little or none of the instructions were 2.4 times more likely to be among women who missed 2 or more pills per cycle. Other factors for inconsistent use included not receiving adequate information or help about OCs from their health care provider (RR = 1.5), and occurrence of certain side effects, including hirsutism (RR = 2.1), nausea (RR = 1.4), bleeding irregularities such as breakthrough bleeding and amenorrhea (RR = 1.3), and breast tenderness (RR = 1.2). Women who were inconsistent OC users, missing 1 or more pills per cycle, were 2.6 times as likely to experience an unintended pregnancy while using OCs than were women who took their OCs consistently. Factors that predicted early discontinuation (women who wished to continue contraceptive protection but discontinued OC use) were primarily side effects, including nausea (RR = 2.1), bleeding in the first 3 months (RR = 1.9), breast tenderness (RR = 1.8), mood changes (RR = 1.8), hair growth (RR = 1.7), and weight gain (RR = 1.4). Multiple side effects substantially increased the likelihood of discontinuation, with a single side effect increasing the risk by 50%, 2 by 220%, and 3 by 320%. Improved compliance can be facilitated if providers emphasize the need to continue to take OCs reliably even if side effects do occur.

Characteristics of condom use and associated problems: experience in Bangladesh.

Data from the 1983 Bangladesh Condom User Survey (BCUS) are analyzed for patterns of condom use and various problems directly influencing their effectiveness. The survey was undertaken to explain an apparent gap between reports of the number of condoms distributed in certain areas compared with prevalence of users as reported in contraceptive prevalence surveys. These data are analyzed from behavioral and management perspectives to identify various factors influencing utilization, with potential implications for understanding and improving family planning and AIDS/STD prevention service systems. Patterns of use are related to differences in source of supply through public, free or private-priced systems, differences in urban or semi-rural place of residence, and differences in perceptions of men or women. The problem with condom use most often identified by the respondents was breakage.

PIP: This study examined patterns of condom use reported in the 1983 Bangladesh Condom User Survey, stemming from a gap between high condom distribution figures and low use reported in the Contraceptive Prevalence Surveys of 1979 and 1981. In order to study populations with high enough prevalence to analyze, only certain young, urban and semi- urban, high and middle-income groups in Dhaka and surrounds were sampled. In these subjects, condoms were the most prevalent method in urban, and pills the most common method in semi-rural couples, who used condoms 4th after tubectomy and the safe period. 20% of urban, and 30% of semi-rural couples purchased their condoms, even though free supplies were available. Reasons cited were to save time, convenience, and embarrassment over accepting free condoms. 56-60% stated that they used condoms at every coitus; 14-20% said most of the time. 66-71% of urban and 22-49% of semi-rural people reported switching methods, mainly because of side effects and complications or fear of side effects. Breakage was reported by 43% of men and 30% of women, or a mean of 3-5 breaks in a 2-3 year period. Over 10% of urban women reported allergic reactions. Implications of these findings for program managers included: charge a nominal fee for condoms in many locations; teach people that condoms have no side effects; educate new users on how to avoid breakage; possible problems with shelf-life.

Contraceptive use and attitudes in Great Britain.

In order to update current knowledge on contraceptive use and attitudes in Great Britain (i.e. England, Scotland and Wales), a survey was conducted among 1753 randomly selected British women aged 15-45. Replies were received from 967 women (55.2%). Seventy-three percent (73%) of fertile, sexually active women who wished to avoid pregnancy were using reliable methods of contraception, viz. oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. However, it was found that adolescents and women over 40 who wished to avoid pregnancy were, nevertheless, especially likely not to be using any contraceptive method at all. The women surveyed were concerned about weight gain, cardiovascular and cancer risks associated with OC use, and infection and infertility risks associated with IUD use. Sixty percent (60%) perceived sterilization as a major and risky surgical operation. It was concluded that contraceptive practice in Britain had not improved greatly in recent years. The latest scientific findings regarding the true advantages and disadvantages of OCs, IUDs and sterilization, therefore, need to be brought to the attention of the lay public more effectively. Special efforts need to be directed towards providing adolescents and women over 40 with proper information. Physicians and the mass media could play a considerable role in this respect.

Adolescent knowledge and use of injectable contraceptives in developing countries.

PURPOSE: To review recent survey data on knowledge and use of injectable contraceptives among adolescents and young women in developing countries. The proportion of adolescents who are aware of this method, who have ever used it, and who are currently using the method, are described. Use of the injection is compared to overall use of any method, as well as to use of two other specific methods, the contraceptive pill and the condom. METHODS: The data reported here come from a series of nationally representative surveys carried out in 25 developing countries, in the mid to late 1980s, as part of the Demographic and Health Surveys (DHS) project. These are surveys of 5,000-10,000 women aged 15-49 years that obtain information on whether women have heard about each specific method, as well as on ever-use and current use of contraception. The data presented here are compiled from published sources, and focus on currently married young women (15-24 year olds), and adolescents (15-19 year olds). RESULTS: Although the injection is recognized by a moderately high proportion of young women and adolescents (40-70% in most countries), use of this method is extremely low in almost all countries. The exceptions, based on DHS data, are 3 Asian countries (Indonesia, Sri Lanka and Thailand) and to a lesser extent, two Latin American countries (Colombia and Mexico). Other countries with moderately high levels of use of Depo-Provera, based on other sources, are China, Jamaica and New Zealand. However, apart from these few countries, when adolescents and young women do choose to use contraception, it is the pill that they are much more likely to choose. CONCLUSIONS: Problems of availability of supplies of the injection may explain some of the observed variation in levels of use of this method. Supplies are mostly provided by international donor agencies such as United Nations Fund for Population Activities and International Planned Parenthood Federation. The lack of approval of the method by the United States until recently also probably had a negative effect on the likelihood of some other governments approving this method or promoting it. Now, with the approval of the United States, supplies may become more available and there may be a greater willingness to use Depo-Provera and other injectables in the developing countries.

PIP: A review of the findings of Demographic and Health Surveys carried out in 25 developing countries (10 in sub-Saharan Africa, 3 in North Africa, 3 in Asia, and 9 in Latin America and the Caribbean) in 1986-90 indicates a high degree of awareness of injectable contraception but very low levels of use. Over 80% of women 15-49 years of age in Indonesia, Sri Lanka, Thailand, Botswana, Colombia, and Mexico knew of the injectable contraceptive Depo-Provera; in the other countries, awareness was in the 40-70% range. In countries for which separate data were available for women 15-19 years of age, knowledge of injectable contraceptives tended to be 10-20% less than that for all women. In 13 of the 25 countries, knowledge of injectables was 20-30% less than that of the pill; however, injectable contraception was more recognized than the condom in 17 countries. There were only five countries--Indonesia, Sri Lanka, Thailand, Colombia, and Mexico--in which 10% or more of married women have used Depo-Provera. Among married adolescents, the highest rate of Depo-Provera use (7%) was found in Indonesia and Thailand; in other countries for which data on adolescents were available, use levels were in the 1-2% range. These low use levels are assumed to reflect both women's health concerns and the nonavailability of supplies from international donor agencies. However, recent approval by the US of Depo-Provera use is expected to increase its availability in developing countries.

Adolescent girls' attitudes toward contraceptive subdermal implants.

Norplant, which has been shown to be a highly effective and acceptable contraceptive for adult women, may also be a very useful contraceptive for adolescents. This study is designed to determine the level of interest in Norplant for adolescent girls with and without children, their attitudes toward various features of Norplant, and the demographic and psychosocial factors predictive of their interest. A self-administered questionnaire was given to 112 adolescents attending our pediatric or adolescent clinic. Data from 28 adolescent mothers and 79 nulliparous adolescents were analyzed. Fifty-six percent of the subjects had heard of Norplant prior to the survey. The overall level of interest in Norplant was high; 70% of the adolescents without children, and 79% of the adolescent mothers were interested. In comparison to oral contraceptives, 73% of those without children and 89% of those with children thought Norplant would be a better contraceptive. The specific features of Norplant liked by 87% and 81% of the subjects, respectively, were not needing to take pills every day and its effectiveness in preventing pregnancy. The characteristics seen as most undesirable related to potential side effects with acne being mentioned by 87% of the subjects. Recursive partitioning analysis demonstrates that more than one prior pregnancy was the main characteristic predictive of very high levels of interest. In summary, this study demonstrates high levels of interest in Norplant by adolescents and suggests that it should be offered as a contraceptive option, especially to those girls who have previously been pregnant.

PIP: Questionnaires completed by 107 adolescents (average age, 16.5 years) recruited from Florida clinics indicated substantial interest in Norplant contraceptive implants, especially among those with a previous pregnancy. Included in the sample were 28 adolescents 13-20 years of age who were caring for one or more children. 40 (55%) of the adolescents with a history of sexual activity acknowledged having intercourse in the past year without use of contraception. Overall, 56% had heard of Norplant prior to the survey; the mass media was the primary knowledge source. 70% of those without children and 79% of adolescent mothers stated that they were interested in the method; moreover, 73% of nulliparous women and 89% of mothers thought Norplant would be superior to oral contraceptive use. Convenience and effectiveness were the most frequently cited positive aspects of Norplant. On the other hand, significant percentages of adolescents expressed concern about Norplant-related side effects: acne (87%), headache (83%), weight change (71%), and menstrual irregularities (71%). The main predictor of interest in Norplant was number of pregnancies; the 12 adolescents who had two or more previous pregnancies expressed the highest degree of interest. Early age at menarche (12.5 years and under) and a high number of sexual partners (4.5 and above) were also positively associated with interest in Norplant. Thus, adolescents who are most at risk of an unintended pregnancy are also the subgroup most receptive to Norplant use.

The benefits of school-based condom availability: cross-sectional analysis of a comprehensive high school-based program.

OBJECTIVES: To analyze the benefits of a school-based condom availability program relative to the risks that such a program may incur. METHODS: A confidentially-administered survey instrument was completed by 152 randomly selected high-school students (approximately 14% of the entire student population). RESULTS: The respondents had a mean age of 15.9 years (range: 14-19 years) and a proportionate gender distribution. Ninety-three percent of all respondents had "heard of" the school's program and knew from whom they could receive condoms. Twenty-six percent of the respondents had received condoms from the program with 67% using them. Of those receiving condoms but not using them, more than half did not need them, owing to absence of anticipated sexual activity. Of the nonreceivers, 53% had never had sexual intercourse and 27% received condoms from other sources. The benefit of the program by aiding a sexually-active student was found to be more than three times as great as the risk of encouraging a nonsexually active student to have sexual intercourse (RR = 3.2; 95% C.I. = 2.1, 4.9). The prevalence of sexual activity among all respondents was not significantly higher than the state's average based on gender and age (59.8% vs. 54.5%; z = 1.24, p > .05, n.s.). CONCLUSION: Given the lack of increased sexual activity and the favorable benefit-risk ratio, we conclude that school-based condom availability is successfully utilized by sexually-active adolescents and may be an effective means to reduce potentially harmful outcomes, such as unintended pregnancy and sexually-transmitted diseases.

Patterns of contraceptive use and pregnancy among young Hispanic women on the Texas-Mexico border.

Our objective was to identify significant family planning and health access problems of young Hispanic women on the Texas-Mexico border. Samples of 300 young Hispanic women living in each of the twin cities of El Paso and Juarez were interviewed regarding their knowledge, attitudes, and experiences with respect to birth control, pregnancy, maternal and child health, and health-care services. Knowledge and attitudes of the women about birth control technology were assessed along with their beliefs regarding the use of such technology. Results showed that contraceptive knowledge and usage patterns for young Hispanic women in Juarez and El Paso were significantly different. They relied on different types of birth control methods and also differed with respect to confidence in these methods and related medical services. Both groups reflected positive attitudes toward both child bearing and use of birth control although Juarez women were significantly more favorable toward child bearing. Both groups overwhelmingly favored female doctors. The young women studied have accepted the need for birth control, prefer fewer children, and have some degree of confidence in medical services. Their knowledge and use of reliable versus unreliable birth control devices appear to be major areas requiring culturally sensitive intervention.

PIP: Social work students administered a questionnaire to 600 randomly selected adolescent females from El Paso, Texas, and Juarez, Mexico, to examine their knowledge and use of contraceptive methods and their attitudes about pregnancy, contraception, and child care. 11.7% of the El Paso respondents and 16.7% of the Juarez respondents had been pregnant at some time. Oral contraceptives (OCs) were the most known contraceptive method. Women in El Paso were more likely to be familiar with OCs (98% vs. 91.3%), condoms (93.7% vs. 74.7%), vaginal methods (79.7% vs. 67.8%), and withdrawal (65.3% vs. 44.5%) than were those in Juarez (p = .001). On the other hand, more Juarez women than El Paso women knew about injectables (79.8% vs. 34.1%), sterility or tubal ligation (89.9% vs. 63.3%), vasectomy (73.2% vs. 69%), Billing's method (19.2% vs. 5.3%), and the rhythm method (73.6% vs. 36.4%) (= = .001). Many women from both cities used ineffective methods. Women in Juarez were much more likely to use the rhythm method than those in El Paso (26.4% vs. 3.4%; p = .001). Women from both cities, particularly those in Juarez (p = .001), believed more information on contraception was needed. They felt strongly that men should also be responsible for family planning and approve of women using contraceptives. They believed that couples should have fewer children. Juarez women has a more positive view of pregnancy and childbearing than did El Paso women. El Paso women were more likely to visit a physician in the last year for reasons other than check-ups (mean number of visits, 1.88 vs. 1.25; p = .005). Most women preferred to receive maternal and child health/family planning services from a female physician (56% in Juarez and 64.3% in El Paso). These findings indicated that cultural differences in contraceptive knowledge and usage as well as confidence in various methods and related medical services existed. They emphasized the need for culturally relevant education, research, and service programs concerning adolescents in the Texas-Mexico border region.

Adolescent use of Norplant implants: clinic services, policies and barriers to use.

INTRODUCTION: The purpose of this article is to review the experiences of family planning clinic providers in making Norplant available to adolescents. We look specifically at the proportions of women receiving the implant from these providers who are teenagers, the policies adopted regarding implant education and whether or not parental consent is required for minors. Pricing policies and the implications of high method cost for teenagers are discussed. Finally, some of the policies adopted by state agencies related to adolescent use of the implant are reviewed. METHODS: The data come from two national surveys conducted by the Alan Guttmacher Institute (AGI). The first, a survey of family planning agencies, collected data from 616 family planning providers of clinic services (response rate 69%). The second surveyed the Medicaid, health and welfare agencies in all 51 jurisdictions about policies related to Norplant. RESULTS: Over one-quarter of all contraceptive implants inserted by family planning agencies were provided to teenagers. Teenagers were routinely informed about the implant in about 85% of those clinics offering implant services. Few state agencies notify women about the implant. Twenty-three percent of all family planning agencies providing implant services report that parental consent must be obtained prior to implant insertion. The Medicaid program has paid for a majority of implant insertions at family planning agencies. CONCLUSIONS: Teenagers who rely on publicly funded family planning clinics for contraceptive services face a variety of barriers in obtaining Norplant. High method cost, parental consent requirements and issues related to Medicaid eligibility are likely to deter some teenagers who might otherwise choose Norplant.

PIP: Data from two national surveys conducted by the Alan Guttmacher Institute--the Family Planning Monitoring Survey and the Norplant Accessibility Survey of State Agencies--enable a preliminary assessment of the extent to which US family planning programs have succeeded in making Norplant available to teenagers. By September 30, 1992, 40% of US family planning agencies provided Norplant and another 13% were about to begin distribution. During the first 18 months of Norplant availability, teenagers were recipients of 27% of all contraceptive implants inserted by family planning agencies. By the end of 1993, about 75,000 teens had obtained Norplant from family planning agencies by the end of 1993 and another 60-65,000 received the implants from private providers. The median cost of Norplant insertion is US$500, but 60% of insertions are funded by Medicaid. Although 85% of clinics routinely inform teenagers about the Norplant option, state health and welfare departments and Medicaid have made little effort to promote Norplant use. 23% of agencies that offer Norplant require parental consent for minors; this requirement varies, however, from a low of 6% of Planned Parenthood affiliates to a high of 40% of hospital-based programs. Potential deterrents to continued high use of Norplant by teenagers include a lack of confidentiality, Medicaid limits on the number of funded insertions, and loss of Medicaid benefits when a teen leaves home or is more than 60 days postpartum.

Contraceptive implant use among inner city teens.

PURPOSES: This study develops a clinical profile of urban teens who selected Norplant for contraception; determines which variables identify the subjects most likely to be compliant with the method; and determines the most common reasons for early termination of use. METHODS: Demographic and health history data and reasons for termination of use were collected prospectively for 122 inner city teens who received Norplant. Life table analysis and the Mantel-Haenszel procedure were used to investigate differences between Norplant retainers and terminators. RESULTS: The sample consisted of black and Hispanic teens between the ages of 13-19 years, the majority of whom had one or more children and were in school. One and two year retention rates were 71% and 62%. The highest removal rates occurred during the 3-6 month interval after insertion. A significant finding was that teens who have experienced induced abortion were more likely to retain Norplant. Common reasons for termination of use included general and social concerns, including pregnancy desire. CONCLUSIONS: Norplant retention rates for this teen sample were greater than the compliance rates reported for other conventional methods. Similar to noncompliance with oral contraceptives, discontinuance of the method was most likely to occur in the first 6 months of use. A history of induced abortion identifies those teens most likely to retain Norplant, suggesting that these teens might evaluate contraceptive risks and benefits differently than those with no abortion history. Pregnancy desire was a common reason for terminating Norplant use.

PIP: This prospective study of 122 Black and Hispanic inner-city adolescent Norplant users recruited from a teen clinic in Rochester, New York, was the first to include a two-year follow-up period. The study period extended from June 1, 1991, to June 30, 1993. The mean age of Norplant acceptors was 17.4 years; 76% had a parity of at least one. Recorded was a one-year retention rate of 71% and a two-year rate of 62%. The greatest number of removals occurred in the first three months after insertion. There was no association between Norplant retention and age, weight, race, parity, or school status. The only significant predictor of Norplant continuation was a history of at least one induced abortion. The reasons most frequently cited by the 30 adolescents who discontinued Norplant were headache, fatigue, hair loss, nausea, weight changes, breast symptoms, and appetite changes. Menstruation irregularities were reported only by terminators in the 3-6 month use interval. Considering the high continuation rates recorded in this survey and the method's proven effectiveness, Norplant has the potential to widen substantially the birth interval between adolescent pregnancies.

Sexuality, sexual behaviour and contraception in East Germany.

Social factors may influence sexual health and its related behaviour. The political changes in East Germany have revealed a positive attitude towards sexuality and the use of family planning methods. A study on sexual behaviour and the use of contraceptives was undertaken recently, at the end of the old regime and the beginning of the new one. The survey was performed among 3103 male and female respondents (pupils, students and workers) of between 16 and 48 years of age. The results show a decreased number of stable partner relationships among young people, however, love and sexuality are considered to be central values. Before the age of 19 years, the majority of girls (80%) and boys (68%) had had sexual intercourse for the first time, a rate which has not changed during the last decade. There is a tendency to postpone having a first child. Modern contraception is widely accepted and used. There is a growing number of condom users, however, the pill is still the most popular method. Family planning is much more advanced than in the other countries of Eastern Europe. Sex education and counselling should sustain this situation.

PIP: In 1990, the Central Institute for Youth Research in Leipzig, Germany, conducted the Partner Study III which consisted of 3103 pupils, students, and factory workers in the former East Germany, 16-48 years old, to determine society's influence on partner relationships, sexuality, sexual behavior, and family planning use. Just 25% of 16-year-old males and 50% of 16 year-old-females had a stable partner relationship compared to 75% and 93%, respectively, for 16-year-olds in earlier studies. Almost everyone (99%) had premarital sexual intercourse. Mean age at first intercourse was 17, which usually occurred in a stable partnership (77% of males and 85% of females). 67% of 16-18 year old couples had agreed on contraception, especially oral contraceptives (OCs) and condoms (75% and 32%, respectively), before first intercourse. Most respondents considered love and sexuality to be central aspects of their lives. Respondents had sexual intercourse 8-9 days/month. Most women (91%) had had a recent orgasm. Most people wanted to marry, but later than they did previously, and to have children (87% and 99%, respectively). Yet, many East Germans were delaying childbearing. 99% favored contraception. Most people considered contraception to be the responsibility of both men and women. Acceptance of contraception did not include acceptance of abortion as a birth control method. Yet, few wanted to make the liberal abortion law more restrictive. The most commonly used contraceptive methods were OCs (66%) and condoms (62% vs. 35% in 1980). Overall, the sample had a good knowledge of contraceptive methods. More than 90% favored OCs. More than 80% accepted the condom. They considered it to be morally sound to carry a condom due to the threat of AIDS. Yet, few used a condom for each act of coitus. Safe contraception was a prerequisite for sexual intercourse for 79% of youth. Youth in East Germany tended to have a serious attitude of responsibility towards one's partner, contraception, and sexuality.

Contraceptive use and attitudes in reunified Germany.

Contraceptive use and attitudes were assessed in a random sample of 1064 German women. The majority (76%) of the sexually active, fertile women who were not pregnant and did not wish to get pregnant at the time of the survey were using very reliable contraceptive methods, namely oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. Comparison with a previous survey showed that contraceptive practice in West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. It is concluded that German contraceptive practice is reasonably effective and that if attitudes were to become more realistic the level of effectiveness could even be raised.

PIP: The sample for this 1992 survey of contraceptive use and attitudes was obtained by random-walk sampling, whereby field workers from a survey agency that collaborated in carrying out the study followed designated routes throughout the country, starting from 257 predetermined locations. They identified subjects 15-45 years old by visiting their homes and inviting the woman in each household to participate in the study. Of the 1064 women surveyed, 75.7% were defined as being exposed to the risk of conception; 3.8% stated they were infertile, 4.2% were currently pregnant, 4.0% intended to get pregnant, and 15.6% were not sexually active. The barrier methods used comprised condoms (10.4%), diaphragms (0.9%), spermicides (0.6%), and combinations of condoms and spermicides (0.4%), of diaphragms and spermicides (0.1%), and of diaphragms and condoms (0.2%). Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. 75.7% of exposed German women used reliable methods, namely OCs, IUDs, and sterilization. Women from what had been East Germany cited the common reasons mentioned for using contraceptives as often as did women from what had been West Germany (p 0.05), except for AIDS and sexually transmitted disease prevention (1.1% and 5.8%, respectively, p 0.05) and alleviation of skin disorders (2.3% and 12.5%, respectively, p 0.01). Information on contraception was obtained mainly from gynecologists (67.7%) and friends (30.9%). Comparison with a previous survey showed that contraceptive practice in the former West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Certain disadvantages of OCs and IUDs were less frequently perceived by women from the former East Germany than by women from the former West Germany, whereas "East German" women were more frequently of the opinion that sterilization was a major and risky operation. German contraceptive practice is reasonably effective, and if attitudes were to become more realistic the level of effectiveness could even be raised.

Family planning practice among Nigerian student midwives.

An analysis of the various contraceptive methods practiced by a total of 462 student midwives from the Northern and Southern parts of Nigeria over a 3-years period is presented. The differences in age distribution, the type of contraceptive agents used, the reasons for using them, and the side effects in the two groups are statistically significant. The need to provide acceptable contraceptive advice to the rural communities by the midwives is discussed.

PIP: An analysis of the various contraceptive methods practiced by a total of 462 student midwives from the Northern and Southern parts of Nigeria over a 3-year period is presented. The differences in age distribution, the type of contraceptive agents used, the reasons for using them, and the side effects in the 2 groups are statistically significant. In order for the midwives to provide acceptable contraceptive advice to the rural communities they need a positive attitude toward contraception, a more involved role in family planning policy, program planning and implementation, special training in family planning practice, and to be equipped to train various community health workers on how to distribute different types of family planning techniques in all the rural areas, especially outside of the hospital setting. This survey showed that there is a high level of awareness of contraception among the Nigerian midwives studied. It also suggests that Nigerian student midwives practice family planning although many probably use less effective methods. Respondents were mostly single and young and a majority were only 3-4 years post-secondary school. The condom was highly favored, but its use requires a high degree of responsibility and self-control. 27.9% practiced the rhythm method, and 16.2% used oral contraceptives, a relatively low proportion. IUD users were few in number. Incidence of side effects for all methods was low. The midwives are in a unique position, by their practice in rural communities, to preach awareness of contraception in order to reduce the high fertility and population rate in developing countries.

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.

Family planning through private practitioners: characteristics of Kenyan contraceptive acceptors.

Kenya has one of the highest population growth rates in the world. Innovative programs are therefore called for to help curb the fast population growth rate. The Kenya Medical Association started a new program of involving private physicians in the active provision of family planning services. A preliminary analysis shows that the program serves generally young, better educated women of low parity. Sixty-one percent of the clients are new acceptors and the oral contraceptive pill the most popular method. The level of education of the clients had marked influence on family size. Age, parity and marital status also influenced the pattern of contraceptive use. These preliminary results are discussed against the background of the 1984 Kenya Contraceptive Prevalence Survey findings and possible areas of improvement suggested.

PIP: Kenya has one of the highest population growth rates in the world. This article describes an innovative new program by the Kenya Medical Association (KMA) involving private physicians in the active provision of family planning services. By the end of 1987, 216 physicians had been recruited and trained to provide family planning information and services free of charge. Information profiles from these physicians were returned monthly to the KMA and they included client profiles, age, marital/educational status, parity, and contraceptive practice. Information from the first 40 private physicians recruited is reported in this article. The 40 physicians had 1626 clients. These preliminary results of the program show that the program serves generally young, better educated women of low parity. 61% of the clients are new acceptors and oral contraception is the most popular method. The level of education of the clients had a marked influence on family size. Age, parity, and marital status also influenced the pattern of contraception usage. These preliminary results are discussed against the background of the 1984 Kenya Contraceptive Prevalence Survey findings. The potential of this new program is exciting because the 2700 private practice physicians and clinical officers can now be used to expand Kenya's 800 service delivery points for family planning at a cost well below current start up costs.