Free Contraception Research Articles

Source of Maternal and Child Health Care as an Indicator of Ability to Pay for Family Planning

CONTEXT: Most developing countries cannot afford to provide free contraceptives to all women who choose to practice family planning. It is important to consider ways of determining which women need government subsidized services and which women can afford to pay for contraceptives. METHODS: Demographic and Health Survey data from eight developing countries are used to determine the proportions of women with children aged five or younger who practice contraception and who purchase private health care for themselves or their children. By assuming that these women can also afford to purchase contraceptives, we estimate how the private sources of contraceptives and the government’s family planning subsidies would be affected if all those who could afford to pay for their methods did so. RESULTS: In three countries—Indonesia, the Philippines and Zimbabwe—if all women who purchased private maternal and child health care were to purchase their oral contraceptives from commercial sources, the private-sector share of the pill market would increase by 22‐26%, while the government’s financial burden for family planning would decrease by 3‐7%. CONCLUSIONS: Encouraging women with the means to pay for private health care to purchase contraceptives from commercial sources could stimulate private sector participation, reduce the stress on overtaxed government family planning funding and allow substantially greater access to those in need of subsidized care. International Family Planning Perspectives, 2002, 28(3):167‐169

Whose choice is it anyway? Decision making, control and conception

Contemporary societies in the developed world are characterized by the expectation that women wish to and are able to control their experiences of fertility. Changes in medical technology and advances in reproductive medicine have played an important role in strengthening this expectation, together with other changes, such as the availability of free contraception. However, this article draws on data from two qualitiative sociological research projects which demonstrate that women's expectations of reproductive choice and control are not always realized. Women's experiences of fertility are mediated by a dominant discourse which assumes that women both want and will achieve biological motherhood. The data indicate that women actively ‘try’ to achieve conception with the expectation that this is both controllable and easy. In some instances this seems to be the case, but many women soon realize that achieving conception is sometimes problematic or, indeed, impossible. This article concludes by arguing that although women may wish to control their experiences of fertility, their expectations of choice and control are frequently an illusion.

The oral contraceptive pill in Viet Nam: Situation, client perspectives and possibilities for promotion

Viet Nam has one of the highest rates of abortion in the world, according to the 1997 Demographic and Health Survey. Even though official statistics and survey fieldwork are likely to have underreported the number of abortions, the rate is still high at 340 per 1,000 pregnancies (Henshaw and Morrow, 1990; NCPFP, 2000a). This can be partly attributed to unmet need for contraceptives among married women and also to the fact that unmarried women do not have access to free modern contraceptives (Nguyen Minh Thang and others, 1999). To deal with this situation, the Vietnamese Government’s family planning programme is expanding the contraceptive mix so that temporary methods such as condoms and oral contraceptive pills are being given more emphasis, especially the pills, as they are so effective in preventing pregnancy (NCPFP, 2000b; Harlap, Kost and Forrest, 1991).

Contraceptive security, information flow, and local adaptations: family planning Morocco.

Many developing countries increasingly recognize and acknowledge family planning as a critical part of socio-economic development. However, with few health dollars to go around, countries tend to provide essential drugs for curative care, rather than for family planning products. Donors have historically provided free contraceptives for family planning services. Whether products are donated or purchased by the country, a successful family planning program depends on an uninterrupted supply of products, beginning with the manufacturer and ending with the customer. Any break in the supply chain may cause a family planning program to fail. A well-functioning logistics system can manage the supply chain and ensure that the customers have the products they need, when they need them. Morocco was selected for the case study. The researchers had ready access to key informants and information about the Logistics Management Information System. Because the study had time and resource constraints, research included desktop reviews and interview, rather than data collection in the field. The case study showed that even in a challenging environment an LMIS can be successfully deployed and fully supported by the users. It is critical to customize the system to a country-specific situation to ensure buy-in for the implementation. Significant external support funding and technical expertise are critical components to ensure the initial success of the system. Nonetheless, evidence from the case study shows that, after a system has been implemented, the benefits may not ensure its institutionalization. Other support, including local funding and technical expertise, is required.

Ends versus means: the role of markets in expanding access to contraceptives.

Achieving and sustaining universal access to contraceptives are key policy goals of interventions supplying contraceptive commodities. Donor support for contraceptive supplies is substantial and many public and national programmes rely on donated and subsidized supplies of contraceptives. Sustainability of programme benefits is a concern to both national governments and donor agencies. At the same time, market-based provision of contraceptives has become a major source of contraceptives for individuals in a number of countries. While the goals or 'ends' of policy are to increase and sustain universal access to contraceptives, there is debate about the role of markets and their negative impacts on equity and universality. There is also concern that while public programmes supplying free contraceptives may, in the medium-term, achieve high coverage, they may hamper the achievement of long-term sustainability and the development of commercial markets. This paper focuses on the tension between the public health and market paradigms, and uses economic analysis as a framework in order to examine the relative roles or 'means' for subsidized public and commercial private sector supply of contraceptives. The review of the theory and evidence focuses on the trade-offs between public sector and market provision of contraceptives, examining the role for the public sector given the potential for market failures, the impact of public provision on the development of markets, and the role of price in demand. However, because of the potential conflict between these policy objectives, we argue that strategies to deliver contraceptives should be based on the specific characteristics of the context. In particular four variables (contraceptive prevalence rates, HIV prevalence, income level of country, size and geographic spread of private sector development) are important in characterizing this context, and these are highlighted in a matrix of programme priorities. Public choices need to take into account the ways in which they will affect the potential for development of sustainable private sources of supply. Undertaking a 'market assessment' should be a key stage in the analysis of policy options. Such an assessment should address demand factors, health priorities, actual and potential sources of supply and the relationships between public and private supply. Clearly the development of markets for contraceptives is not an end in itself, but may prove an important means of improving the health of women and men.

Contraceptive Security, Information Flow and Local Adaptations: Family Planning in the Philippines and Morocco

Family planning programs, a vital ingredient of socioeconomic development, form a cornerstone of national policy in ma ny developing countries. After the 1994 International Conference on Population and Development in Cairo, governments have increasingly acknowledged the importance of family planning, particularly in opening opportunities for socioeconomic development (UNFPA 1994). Government spending on health, however, tends to give priority to curative rather than preventive care, and scarce health resources are allocated for essential drugs rather than contraceptives (World Bank 1993). To ensure the security of fami ly planning programs, therefore, donors have historically provided free contraceptives to governments and organizations that offer family planning services. Family planning programs depend on the uninterrupted flow of contraceptive s through multiple levels of the supply chain, ranging from central warehouses to health clinics and community-based distributors. Failure of the supply chain—or logistics system —causes an erratic supply of contraceptives, which may result in loss of credibility and eventual failure of the family planning program. Ensuring the continuous availability of contraceptives at the client level is a key contributor to increasing the use of family planning services (Ngallaba et al. 1994). The driving force behind a logistics system is a well-functioning logistics management information system (LMIS) (Christopher 1994). Efficient management of the flow of information on stock levels and consumption from lower levels to the center stimulates the flow of contraceptives back down the supply chain. An LMIS helps determine what quantities of each product need to be sent to a particular location at the correct time, for the optimal cost. The flow of stock-level and consumption data along the same channels can inform decisions critical to meeting current and future family planning needs.

Safe Third Countries: Extending the EU Asylum and Immigration Policies to Central and Eastern Europe by Sandra s> Lavenex (review)

REVIEWS 387 the main means of fertilitycontrol. This is particularlyimportant given the strong association between lack of contraception and maternal, infant and perinatalmortality(Kovacs, p. 9 I). Moreover there is an absence of integration of health and education, in particularsex education, and a similarlackof coordinationprevailswith regardto linksbetween health care and police and social services. These points, and general considerations of economic dislocation , are not part of a sustainedanalysisor a unified theme developed in particularchapters. Despite the recognition of variation between and within countries,and numerouschartsand tablesto illustratethe former,there is no sustained comparative analysis of the reasons for such differences. The political, social and economic context of post-Communist transformation appearsonly at the margins.The particularissuessurroundingredefinitionof gender roles and the specific impact of this profound change on women are addressednot at all. Moreover, the solutions offeredare either obvious or wildly unrealistic.In the first category are pleas for the establishment of efficient and sensitive family planning services and free contraception. The second includes recommendationsfor a qualityassuranceprocess,includingsetting'standards for quality of care in structure, process, and outcomes' (Lindmark,p. 30). Scholarsand otherinterestedpersonswillfindlittleto stimulatetheirinterest. Department ofGovernment FRANCESMILLARD University ofEssex Lavenex, Sandra. SafeThirdCountries. Extending theEU Asylum andImmigration Policiesto Central andEastern Europe. Central European University Press, Budapestand New York,i999. xii + I89 pp. Notes. Bibliography.Index. ? 13.95 (paperback). THE aim of this book is to demonstrate that the European Union's (EU's) currentasylumregimewhich isgearedtowardscombatingillegalimmigration, weakensthe principles,normsand rulesof internationalrefugeeprotectionby impeding the entry of asylum seekers and that it establishes a system of negative redistributionfor handling asylumclaimsthat impactsupon Central and EasternEuropean Countries (CEECs).Additionally,the fieldsof asylum and immigration, although not originallypart of the EU's agenda, now play an increasinglyimportantrole in the pre-accessionstrategydeployed vis-a-vis CEECs, and this, the author argues, may place significantobstacles to swift enlargementof the EU and to the realizationof the free movement of persons between the old and new member states. The CEECs (including the EU membership candidates -- Bulgaria, Poland, Hungary, Czech Republic, Romania, Slovenia, Slovakia, Estonia, Latvia and Lithuania as well as other states of Eastern and South-Eastern Europe) now face the conflicting requirements of sealing their borders and, at the same time, upholding the normsof the internationalrefugeeregime. Sandra Lavenex charts the changes that have taken place in the international refugee regime particularlysince the Second W'Vorld WVar. A useful backgrounid isgivento the adoptionby manystatesofthe Refugee Convention 388 SEER, 79, 2, 200 I of I95I and itsextension by the Protocolof I967, both documentsunderlining a willingness to institute governmental recognition of refugee phenomena, if never leading to a complete recognition of a right of asylum. She detects that a change in the internationalfocus occurredwhen Westernstatesbegan to be faced with increasing numbers of asylum applications from non-Europeans, in a context in which most countries had declared officially against labour immigration.Combined with theprospectof droppinginternalborderswithin the EU that member states had undertaken as part of the Single Market project,thismotivateddiscussionand moves towardsthe restrictiveregulation of refugeemigrationamong EU states. Initial moves among EU states in the field of asylum, as reflected in the Dublin and the second Schengen Conventions of I990, concentrated on shifting responsibilityfor asylum claims by the adoption of rules apparently geared towards avoiding multiple asylum applications in different states, effectively preventing intra-EU migration for asylum seekers. These have been furtherdevelopedbytheadoptionofavarietyofnon-bindinginstruments among EU statesthrough more or less secret discussionsin exclusive fora the author remains very concerned by the generally undemocratic character of norm setting in this context, and points to the concentration of power in Interior Ministries, and away from national and European Parliamentsand even Foreign and Social Affairs Ministries. Thus different rules have been developed to level down asylum guarantees especially by concentrating on preventing or limiting access to determination procedures and facilitating faster expulsion measures. Notably, norms have been accepted to the effect that non-EU countries should be identified as targets to which unsuccessful applicantsshouldbe expelled (especiallyunderthe 'safethirdcountry'or 'safe countryof origin'rules),and thesehave been bolted down with a criss-crossof bilateral readmission agreements under which CEECs are made liable to receiveexpellednationalsand alienswho havepassedthroughtheirterritories. The scale of the impact of such agreements can be appreciated when the author tells of 8s,ooo people who were expelled from Germany to...

Towards Better Reproductive Health in Eastern Europe. Concern, Commitment and Change by G. s> Lindmark M. Horga A. Campana , J. Kasonde (review)

386 SEER, 79, 2, 200I This is definitelynot a book to be recommended to mainstreameconomists, and not even to 'transitologists'keen on economic developmentsonly. This is a book to take on an air flight or better a railway trip and to enjoy withoutprejudice. ISMEA(Institute ofApplied Mathematics andEconomics) M. LAVIGNE Paris Lindmark,G.; Horga, M.; Campana, A. and Kasonde,J. (eds). Towards Better Reproductive HealthinEastern Europe. Concern, Commitment andChange. WHO Scientific Working Group on Reproductive Health Research. Central European University Press, Budapest, and WHO, Geneva, I999. xiv + 150 pp. Tables. Figures.Bibliographies.?9.99 (paperback). THE identificationof a significantgap in healthstatusand healthcare between the post-Communist countries and those of advanced Western economies predatedthefallof Communism,but the shocksand dislocationsof 'transition' saw the gap widening. Graveconcernshave been expressedfor manyyearsat the numerous examples of deteriorating indices of health, including basic indicators such as life expectancy and infant mortality. Premature male mortalityattractedparticularattention.Onlyveryrecentlydidtheseindicators improve in certaincountriesof CentralEurope;but furtherdeteriorationwas evident throughoutmost of the formerSoviet Union. A study of reproductive health ought therefore to be very welcome, not least because the health gap is paralleledby a researchgap in this area. Even the thoughtful,wide-rangingrecent studyby William Cockerham(Healthand SocialChange inRussiaandEastern Europe, London, i999) largelyignoreswomen in generaland reproductivehealthin particular.Unfortunately,thiscollection of chaptersby the WHO ScientificWorkingGroup on Reproductive Health Research is tedious and repetitive. Its data are drawn mainly from the first half of the I99os, so that it does not even have the merit of providing an upto -date overview. Some of the data do not appear consonant with those available elsewhere, such as the surprising figures for life expectancy in Turkmenistan of 62 years for women and 69 for men (Honjanen and Benagiano, p. 2). It is not that the materialsprovided offeran erroneouspicture. Indeed, the problems identified will be all too familiar to the 'policymakers and programmemanagers'who are the targetaudience. These includehigh levels of maternal and infant mortality, low use of contraception, high abortion rates,yet risingteenage pregnancies, and an epidemic of sexuallytransmitted disease,probablylinkedto infertility.The reasonsadduced for suchproblems are also familiar ones. Some are a result of health care organization and medical practice. They include the lack of emphasis on primaryprevention, poor standardsof medical training (forobstetricsand gynaecology, if not for dermatology and venerealogy), authoritarianattitudes to and little involvement of patients with their care, the persistence of traditionalpractices and obsolete treatmentregimens.Othersarea resultoflackof resources,especially with regardto familyplanning servicesand contraception,with abortion still REVIEWS 387 the main means of fertilitycontrol. This is particularlyimportant given the strong association between lack of contraception and maternal, infant and perinatalmortality(Kovacs, p. 9 I). Moreover there is an absence of integration of health and education, in particularsex education, and a similarlackof coordinationprevailswith regardto linksbetween health care and police and social services. These points, and general considerations of economic dislocation , are not part of a sustainedanalysisor a unified theme developed in particularchapters. Despite the recognition of variation between and within countries,and numerouschartsand tablesto illustratethe former,there is no sustained comparative analysis of the reasons for such differences. The political, social and economic context of post-Communist transformation appearsonly at the margins.The particularissuessurroundingredefinitionof gender roles and the specific impact of this profound change on women are addressednot at all. Moreover, the solutions offeredare either obvious or wildly unrealistic.In the first category are pleas for the establishment of efficient and sensitive family planning services and free contraception. The second includes recommendationsfor a qualityassuranceprocess,includingsetting'standards for quality of care in structure, process, and outcomes' (Lindmark,p. 30). Scholarsand otherinterestedpersonswillfindlittleto stimulatetheirinterest. Department ofGovernment FRANCESMILLARD University ofEssex Lavenex, Sandra. SafeThirdCountries. Extending theEU Asylum andImmigration Policiesto Central andEastern Europe. Central European University Press, Budapestand New York,i999. xii + I89 pp. Notes. Bibliography.Index. ? 13.95 (paperback). THE aim of this book is to demonstrate that the European Union's (EU's) currentasylumregimewhich isgearedtowardscombatingillegalimmigration, weakensthe principles,normsand rulesof internationalrefugeeprotectionby impeding the entry of asylum seekers and that it establishes a system of negative redistributionfor handling asylumclaimsthat impactsupon Central and EasternEuropean Countries (CEECs).Additionally,the fieldsof asylum and immigration, although not originallypart of the EU's agenda, now play an increasinglyimportantrole in the pre-accessionstrategydeployed vis-a-vis CEECs, and this, the author argues, may place significantobstacles to swift...

Explaining trends in teenage childbearing in Sweden.

The teenage fertility rate fell precipitately in Sweden after 1966 and is now one of the lowest in Europe. This decline can be seen in the context of major reforms enacted in 1975 whereby the school sex-education curriculum was revised, contraceptive services were improved, and abortion was provided free and on demand. By means of microsimulation, the possible roles of contraception and induced abortion in causing teenage fertility to fall are examined. Before 1975, the decline appears to have been caused primarily by an increase in the number of induced abortions. After that date, however, an increase in the use of highly efficient methods of contraception led to a decline in the pregnancy rate in such a way that, even though the proportion of teenagers who sought abortion increased, the abortion rate declined. Parallels are drawn with the experience of other European countries, and contrasts with that of the United States, where no such developments have occurred, are noted.

Prospective study of barrier contraception for the prevention of sexually transmitted diseases: study design and general characteristics of the study group.

The AIDS epidemic has brought barrier contraceptives to the forefront of public health research. A comprehensive evaluation of the efficacy of barrier contraceptive use in preventing sexually transmitted diseases (STDs), including AIDS, is necessary to inform both potential users and public health policy makers. This study was undertaken to evaluate the efficacy of condoms and vaginal spermicide products, used alone or in combination, in preventing gonorrhea and chlamydia among women attending an STD clinic. To describe the general characteristics of the study group and its follow-up experience. Women who met the eligibility criteria were invited to participate. The initial visit included an interview, a behavioral intervention promoting barrier methods, a physical examination, and instructions to complete a sexual diary. Participants received free barrier contraceptives and returned for six monthly follow-up visits. DESIGN RESULTS: Participants (n = 1,122) were low income, single (74%) black (89%) women with a median age of 24. The behavioral intervention led to the use of barrier protection in more than 70% of reported acts of vaginal intercourse. Barriers were used consistently (100% of sexual acts) during 51% of the months of follow-up. A total of 148 cases of gonorrhea (28 per 1,000 months) and 122 cases of chlamydia infection (23 cases per 1,000 months) were diagnosed during follow-up. This study represents a practical solution to a complex set of design considerations. The study protocol was successful in promoting consistent and proper use of barrier methods.

Financial Support of Children and the End of Welfare as We Know It

ly, the sensible strategy would seem to combine two goals: discouraging unmarried teen motherhood in the first place and, when it occurs, providing assistance for the child of the teen mother in a new format. Converting these principles into an agreement is not easy, however. As usual, there are both carrot and stick approaches. As for the first goal, a typically recommended stick is simply to deny AFDC to the minor mother, 5 requiring her to be supported by her own family. If her own mother is on AFDC, then the new child is added as a grandchild to the grandmother's AFDC benefit unit, a result which generally brings in a small amount of additional cash. This approach at least discourages young women from getting pregnant for the purpose of moving away from home and using the AFDC grants to rent their own apartments. Unfortunately, at least some young women who are so motivated appear to decide on this course of action in response to violence that is directed toward them in their mother's home. 6 115 For a discussion of the Clinton bill's approach to teen pregnancy, see Jodie LevinEpstein, Center for L. & Soc. Pol'y, Teen Pregnancy Prevention and Teen Parents, July 27, 1994. 116 Mike Males, Correspondence, New Republic, Jan. 2, 1995, at 4 (letter to the editor stating that two-thirds of teenage mothers are past victims of s6xual abuses inflicted by men averaging more than 25 years old). (Mike Males is a doctoral student in social ecology at the University of California, Irvine.) 2570 [Vol. 81:2523 Financial Support of Children This sad reality has caused liberals to oppose the cut-off if no exceptions are allowed. Another stick some conservatives have advocated would force pregnant teens to leave their regular high school and attend school elsewhere. This recommendation, which cuts in exactly the opposite direction to the efforts in which liberals have been engaged over the past two decades, is premised on the idea that too many teen mothers today are seen as receiving special treatment by their peers and, as such, set very bad examples. Yet another stick entails leaning on the fathers of these children. One way, as earlier discussed, would be to force the fathers to work and then to pay child support out of their earnings. 7 Even if it cost money to create the needed jobs for this group, the hope is that the threat would discourage more of these men from getting women pregnant. An alternative gambit would be to start enforcing the statutory rape laws-a role that prosecutors seem to have abandoned in recent times. Liberals, not surprisingly, have tended to. favor carrots. One is to provide poor teens with free contraceptives and free abortions. These measures, it is argued, at least curtail teen mothering that is not truly the young woman's choice. Right-to-life politics has tended to keep Republicans from endorsing these ideas. A different carrot would be to bribe young women not to become pregnant. For example, in selected high schools, females could volunteer to submit to regular (say, monthly) pregnancy tests on the understanding that if they passed they would receive so much money each time. If the amount were large enough to make a real difference in helping them to purchase desired items (e.g., clothes or CDs), this could have an impact. Indeed, it could change high school culture regarding the desirability of pregnancy in schools where it is now a common phenomenon. It would only be costeffective, of course, if it prevented enough births that the resulting social savings would cover what inevitably would be payments to many who would not have become mothers even without bribery. As noted earlier, conservative qualms about paying people to do the right thing might reduce support even if this tactic paid for itself, if only by the health care costs thereby saved. Furthermore, 117 See supra text accompanying notes 70-78. 1995] 2571

The influence of social class on parity and psychological reactions in women coming for induced abortion.

To test the hypothesis that the correlation between legal abortion and socio-economic conditions, known from the time when abortion was restricted, has current validity. To evaluate the effect of social class on network support and psychological reactions. Consecutive sampling and semistructured personal interviewing. 444 women living in the city of Gothenburg and applying for legal termination of pregnancy in the first trimester. The department of gynaecology at a university hospital with primary care responsibility for legal abortions. The 667 health administration districts of Gothenburg were ranked into four groups according to the mean income. Women living in lower socio-economic districts were younger. Irrespective of age, previous experience of induced abortion was more common among them (p < 0.001). Unsatisfactory network response or support was common (37%), but equally shared between the social classes. Discontinuation of oral contraception during the previous six months was twice as common among teenagers (40.0%) as among other women (p < 0.001) but without social differences. Pitman's permutation test was used for statistical analyses. Socio-economic conditions have a strong and inverse correlation to previous experience of induced abortion. Psychological reactions and needs did not vary with class.

The Impact of an Increase in Family Planning Services on the Teenage Population of Philadelphia

In an assessment conducted 30 months after a Philadelphia-area project increased the resources that community family planning agencies devoted to teenage services, teenagers in targeted communities showed no generalized improvement in rates of pregnancy and childbearing, in knowledge or use of clinic services, or in attitudes toward contraception compared with those of teenagers in the entire city. Samples of adolescents aged 14-18 from the clinics' catchment areas and from the entire city were interviewed in mid-1988, when the project's activities began, and 2.5 years later. The results suggest that while community family planning clinics may provide effective services to the teenagers who seek them out, they may not be the most effective strategy for decreasing rates of pregnancy and childbearing in the overall teenage population.

Private-Sector Family Planning Projects Can Succeed Long-term, Even When Donor Support Is Withdrawn

In 1985 the US Agency for International Development set up an Enterprise Program to develop ways of encouraging the private sectors involvement in the promotion and provision of family planning services. 2 years after the end of the program a follow-up study was conducted to evaluate project sustainability. Case studies were conducted on a convenience sample of 25 projects (16 employment-based and 9 market-based) that seemed representative of the program operations. Overall it was found that private sector provision of family planning services can succeed in developing countries even when financial support is withdrawn. It was also indicated that sustainable employment-based programs usually had strong support from the management of the company close links to family planning nongovernmental organizations and access to free or low-cost contraceptives. In terms of the market-based programs those that were sustained were noted to be the most entrepreneurial. The programs were best at combining the provision of family planning with the provision of lucrative health care services at setting competitive prices and at operating efficiently. Three characteristics critical to the success of such projects were identified. These include an active partnership between the company and private- or public-sector institutions strong support from upper management and the financial health of the company.

The sexual behaviour of young people

Chlamydia trachomatis is currently the major sexually transmitted disease (STD) in Sweden. In the early 1980s 20% of young clinic attenders were infected. Treatment policies, including partner tracing, instituted in 1988 reduced the prevalence to less than 5%. Pelvic inflammatory disease (PID) has also declined with the decrease of gonorrhea and chlamydia. The improvements can be associated with policy: the introduction of compulsory sex education at school in 1956 and the establishment of youth clinics in the 1970s with contraceptive counselling, screening, and treatment for STDs. a 1992 study of more than 9000 sexually active Swedish teenagers revealed that 99% considered the condom the most effective means against STDs, and 84% recognized chlamydia, HIV/AIDS, gonorrhea, and genital warts as STDs. 75% of the subjects had engaged in coitus at first intercourse and 82% at the most recent encounter. 17% had had an STD, and 9% had been or had made somebody pregnant, mostly ending in abortion. In 1975, when the new abortion law was adopted, the teenage abortion rate was high at 30/1000 teenagers aged 15-19. Counseling and free contraceptives reduced the rate by 30% in the next 10 years. However, news about the possible risks of oral contraceptives in the 1980s again boosted the rate from 18 to 25/1000. Recent concerted efforts cut the rate anew. Preventive policies need to convey a positive attitude about sexuality and deal with the basic teenage problems of multiple partners and stress the importance of condom use. Condoms are effective only in stable relationships, and those with less education or those unemployed take more risks, using condoms and contraceptives less frequently. Girls from emotionally poor environments often engage in sex for emotional satisfaction. Openness and further knowledge is needed to ensure the safe sexual behavior of young people.

Iran: The family-planning challenge

The challenge of family planning and lowering the birth rate in Iran is considered to be more than promotional efforts and free contraceptives. Women make the major decisions about family size and determine the marriage age for daughters. Islamic law is against women working for pay because of the mixing of sexes; another disincentive is the high rate of male unemployment. There is little motivation for women to control their fertility. The annual population growth rate in 1983 was 3.9% and the annual population growth rate is 3.3%. The birth rate at the beginning of the Islamic revolution was 2%. Islamic revolutionaries urged reproduction as a means of outnumbering the opposition. Women produced more children in order to replace those lost in the war effort. Oral contraceptives were difficult to obtain and irreversible methods of birth control were not made available. Infertile women sought treatment in order to both serve their country and their religion. Incentives were provided in the form of housing priorities going to large families and subsidies for each family member for purchases. Population policy was reversed around 1987-88. Abortion is illegal but the wealthy can find abortions. The poor suffer from septic abortions. Modern contraceptives are reportedly used by 22% of women; however in rural areas almost 50% of women take the pill incorrectly or use it for short periods of time. Food and housing shortages exacerbate the problems of malnutrition and shelter among low income populations. The shortage of schools has contributed to 3 shifts but still not enough space. The revolution did not bring with it prosperity and an increased standard of living.

Twenty one years of legal abortion.

The effects of the 1967 Abortion Act, legislation which extends to women living in England, Wales, and Scotland, are reviewed. The Act was not backed by any specific allocation of money for facilities or staff within the National Health Service and the service provided has varied from district to district. Yet, the number of abortions increased rapidly in the late 1960s and early 1970s. This process had slowed down by 1974, when the number of abortions dropped for the 1st time. The introduction of free contraception seems to have had an important effect; the number of abortions declined by nearly 9000 from 1973-76, and the abortion rate fell from 11.4 to 10.5/1000 women aged 15-44. The number increased in 1977 and 1978, possibly because of adverse publicity about the side effects of oral contraception (OC). The rate of abortion in Scotland, although lower than the rate in England and Wales, has risen steadily since 1969. An important effect of the 1967 Act has been to reduce the number of deaths due to illegal abortions. In the 1st decade of legal abortion, the proportion of all maternal deaths that were due to abortion dropped from 25% to 7%. The number of recorded deaths due to abortion declined from 160 during 1961-63 to 9 during 1982-84. There were 7 deaths after legal abortions during 1982-84 and 4 during 1985-87. 21 years after the passage of the Act half of all women having legal abortions pay for them. The regional differences in the provision of abortion services have persisted since 1968. The proportion of abortions performed in the 1st trimester increased from 66% in 1969 to 86% in 1987, yet the proportions of early abortions in Britain still compare poorly with other countries. In the US, women have been able to request abortion in the 1st trimester since 1974; by 1977 this led to 91% of abortions being performed in this period. Regional differences in the surgical methods persist, and there may be considerable delays between a woman asking for an abortion and the procedure being performed. A Marplan poll conducted in 1988 reported that 80% of those surveyed thought that women should have the right to choose an abortion in the 1st few months of pregnancy; 15% disagreed, and 5% did not know or did not respond. The number of women coming to Britain for abortions peaked in 1973, when 56,000 came. The rate of abortion per 1000 women in England and Wales is 14.8, a moderate figure when compared to other nations -- rates range from 5.6 in the Netherlands to 181 in the USSR.

Do Contraceptive Prices Affect Demand?

Government-sponsored family planning services in developing countries have traditionally provided free contraceptives to couples who choose to contracept. The advisability of and need for such extensive subsidization is brought into question in this article, based on studies that have compared free and fee-for-service family planning programs. Little difference in demand exists between free and moderately priced services. The importance of price in determining family planning demand is also explored through studies of demand shifts in response to changes in contraceptive prices. Contraceptive price increases in established programs have generally had a minimal effect on utilization. Price reductions in established programs, however, have led to increases in contraceptive demand. These findings suggest that moderate fees can be imposed for family planning services without affecting demand; however, full cost recovery may pose a deterrent to low- and moderate-income couples.

Abortion: The New Standard for U.S. Population Aid

Abortion: The New Standard for U.S. Population Aid

Income and Other Factors Influencing Fertility in China

China has achieved remarkable success in increasing life expectancy and reducing fertility. There is no question that much of this success is due to concerted government efforts. Low fertility is in part the outcome of government efforts to raise age at marriage, to provide free contraceptives and abortion, to use local birth quotas and peer pressure to discourage pregnancy, and, increasingl, to provide economic incentives and disincentives. The paper presents evidence, however, that government programs, although important, have not operated in a vacuum. It has data on rates of population increase for the 29 administrative regions of China and on income and other socioeconomic indicators for those regions. It also has data on yearly vital rates since 1972 by prefecture for one province, and income data and vital rate data (the latter for two seperate years) by county for another. These data allows the paper to considerations of several important questions regarding future population policy in China. The paper's principal concern is whether future economic growth and liberalization can be expected to reinforce government programs to reduce fertility, or whether these developments might weaken policies that have contributed to an already low level of fertility.