CONTEXT:Differences among developed countries in teenagers' patterns of sexual and reproductive behavior may partly reflect differences in the extent of disadvantage. However, to date, this potential contribution has received little attention.METHODS:Researchers in Canada, France, Great Britain, Sweden and the United States used the most current survey and other data to study adolescent sexual and reproductive behavior. Comparisons were made within and across countries to assess the relationships between these behaviors and factors that may indicate disadvantage.RESULTS:Adolescent childbearing is more likely among women with low levels of income and education than among their better-off peers. Levels of childbearing are also strongly related to race, ethnicity and immigrant status, but these differences vary across countries. Early sexual activity has little association with income, but young women who have little education are more likely to initiate intercourse during adolescence than those who are better educated. Contraceptive use at first intercourse differs substantially according to socioeconomic status in some countries but not in others. Within countries, current contraceptive use does not differ greatly according to economic status, but at each economic level, use is higher in Great Britain than in the United States. Regardless of their socioeconomic status, U.S. women are the most likely to give birth as adolescents. In addition, larger proportions of adolescents are disadvantaged in the United States than in other developed countries.CONCLUSIONS:Comparatively widespread disadvantage in the United States helps explain why U.S. teenagers have higher birthrates andpregnancy rates than those in other developed countries. Improving U.S. teenagers' sexual and reproductive behavior requires strategies to reduce the numbers of young people growing up in disadvantaged conditions and to help those who are disadvantaged overcome the obstacles they face.
CONTEXT Given that many communities are implementing community-wide initiatives to reduce teenage pregnancy or childbearing, it is important to understand the effects of a community's characteristics on adolescent birthrates. METHODOLOGY Data from the 1990 census and from California birth certificates were obtained for zip codes in California. Regression analyses were conducted on data from zip code areas with at least 200 females aged 15-17 between 1991 and 1996, to predict the effects of race and ethnicity marital status, education, employment, income and poverty, and housing on birthrates among young teenagers. RESULTS In bivariate analyses, the proportion of families living below poverty level within a zip code was highly related to the birthrate among young teenagers in that zip code (r=.80, p<.001). In multivariate analyses, which controlled for some of the correlates of family poverty level, the proportion of families living below poverty level remained by far the most important predictor of the birthrate among young teenagers (b=1.54), followed by the proportion of adults aged 25 or older who have a college education (b=-0.80). Race and ethnicity were only weakly related to birthrate. In all three racial and ethnic groups, poverty and education were significantly related to birthrate, but the effect of college education was greater among Hispanics (b=-2.98) than among either non-Hispanic whites (b=-0.53) or blacks (b=-1.12). Male employment and unemployment and female unemployment were highly related to the birthrate among young teenagers in some racial or ethnic groups, but not in others. CONCLUSIONS Multiple manifestations of poverty, including poverty itself, low levels of education and employment, and high levels of unemployment, may have a large impact upon birthrates among young teenagers. Addressing some of these issues could substantially reduce childbearing among young adolescents.
CONTEXT:Although unintended pregnancy and sexually transmitted diseases (STDs) are considerable problems in the United States, private health insurance plans are inconsistent in their coverage of reproductive and sexual health services needed to address these problems.METHODS:A survey administered to a market-representative sample of 12 health insurance carriers in Washington State assessed benefit coverage for gynecologic services, maternity services, contraceptive services, pregnancy termination, infertility services, reproductive cancer screening, STD services, HIV and AIDS services, and sterilization, as well as for the existence of confidentiality policies. "Core" services in each category were defined based on U.S. Preventive Services Task Force and other recommendations.RESULTS:Of the 91 top-selling plans on which data were collected, 8% were indemnity plans, 14% were point-of-service plans, 21% were preferred-provider organization plans and 57% were health maintenance organization (HMO)-type products; they had a combined enrollment of 1.4 million individuals. Coverage of core services varied widely by type of plan. While a high proportion of plans covered core gynecologic, maternity, reproductive cancer screening, STD and HIV and AIDS services, nearly half of plans did not cover any kind of contraceptive method. Approximately 13% of female enrollees did not have core coverage for gyneco!ogic services, 19% for matemity services, 75% for contraception, 37% for sterilization and 53% for pregnancy termination; 98% of women and men were not covered for infertility treatment. Most carriers did not have specific policies for maintaining privacy of sensitive health information. Overall, benefit coverage was lower for indemnity, preferred-provider organization and HMO plans in Washington State than has previously been seen nationally.CONCLUSIONS:A sizable proportion of women and men in Washington State who rely on private-sector health insurance lack comprehensive coverage for key reproductive and sexual health services.
CONTEXT:Although the determinants of whether a teenage woman has a nonmarital pregnancy and how such a pregnancy is resolved have been widely investigated, little is known about the effect of her partner's characteristics or the joint influence of the two partners' characteristics on nonmarital teenage pregnancy.METHODS:Data from the 1995 National Survey of Family Growth are used to examine whether the characteristics of teenage women and their partners affect the likelihood of a nonmarital pregnancy and how the pregnancy is resolved. The data are corrected for underreporting of abortions.RESULTS:More than 17% of teenage women are estimated to have become pregnant during their first nonmarital teenage sexual relationship. About 44% of these pregnancies result in a nonmarital birth and about 18% in a marital birth, while 37% end in an abortion. The likelihood of nonmarital pregnancy declines as age at first intercourse rises, but age does not affect how such a pregnancy is resolved. Women who are older than their first partner are more likely to become pregnant than those who are the same age, and their pregnancies are less likely to end in abortion than in a marital birth. Women who are younger than their first partner are no more likely to become pregnant than other women after the effects of other characteristics are taken into account. The male partner's education is negatively associated with the likelihood of nonmarital pregnancy but is positively associated with the likelihood of abortion if a pregnancy occurs. Differences between partners in race or ethnicity do not affect the likelihood of a nonmarital pregnancy but do increase the likelihood that such a pregnancy will end in abortion or a nonmarital birth rather than in a marital birth.CONCLUSIONS:The characteristics of teenage women and their partners appear to play a role in nonmarital teenage pregnancy and its outcome. However, the estimated relationships between one partner's characteristics and the probability of a nonmarital pregnancy and its resolution are generally little affected by whether the other partner's characteristics are also taken into account.
This article discusses the role of Thai husbands as vectors of human papillomavirus (HPV) transmission from prostitutes. Infection with HPV type 16 or 18 among Thai women is the most important factor in the progression of precancerous cervical lesions to invasive cancer. This finding was confirmed from three interrelated studies conducted--two involving women with cervical cancer and one involving commercial sex workers in Bangkok and husbands of a subgroup of women with cervical cancer and controls from the first two studies. The results showed that the great majority of women with cervical cancer had intercourse only with their husbands and their risk of cancer is strongly related to the frequency of their husbands visits to prostitutes as young men; according to investigators most are therefore likely to have acquired carcinogenic types of HPV from their husbands.
This article establishes the link between the media public opinion and population assistance. It presents a synopsis of trends in global population assistance and examines the issue-attention cycle as a means of explaining how issues attract the notice of the media and the public as well as why media reporting public opinion and government responses to global population issues differ. Much of the evidence comes from the US which has been the main source of leadership and resources for population assistance and has well-documented democratic processes and global population concerns. Overall it is noted that through their wavering interest in global population questions the media have played an undervalued role in determining global funding trends for population assistance. The evidence suggests a strong link between donor governments funding for population assistance and media coverage of global population issues in developed countries. Media focus on population matters influence public opinion which in turn influence politicians in developed countries. Therefore its not surprising that donor government support for population assistance increased in years of heightened media attention and public support.
CONTEXT Publicly funded family planning clinics are a vital source of contraceptive and reproductive health care for millions of U.S. women. It is important periodically to assess the number and type of clinics and the number of contraceptive clients they serve. METHODS Service data were requested for agencies and clinics providing publicly funded family planning services in the United States in 1997. The numbers of agencies, clinics and female contraceptive clients were tabulated according to various characteristics and were compared with similar data for 1994. Finally, county data were tabulated according to the presence of family planning clinics and private physicians likely to provide family planning care and according to the number of female contraceptive clients served compared with the number of women needing publicly funded care. RESULTS In 1997, 3,117 agencies offered publicly funded contraceptive services at 7,206 clinic sites. Forty percent of clinics were run by health departments, 21% by community health centers, 13% by Planned Parenthood affiliates and 26% by hospitals or other agencies. Overall, 59% of clinics received Title X funding. Agencies operated an average of 2.3 clinics, and clinics served an average of 910 contraceptive clients per year. Altogether, clinics provided contraceptive services to 6.6 million women-approximately two of every five women estimated to need publicly funded contraceptive care. The total number of providers and the total number of women served remained stable between 1994 and 1997; at the local level, however, clinic turnover was high. Some 85% of all US counties had one or more publicly funded family planning clinics; 36% had one or more clinics, but no private obstetrician-gynecologist. CONCLUSIONS Publicly funded family planning clinics are distributed widely throughout the United States and continue to provide contraceptive care to millions of US women. Clinics are sometimes the only source of specialized family planning care available to women in rural counties. However, the high rate of clinic tumover and the lack of significant growth in clinic numbers suggest that limited funding and rising costs have hindered the further expansion and outreach of the clinic network to new geographic areas and hard-to-reach populations.
CONTEXT:Although the number and rate of tubal sterilizations, the settings in which they are performed and the characteristics of women obtaining sterilization procedures provide important information on contraceptive practice and trends in the United States, such data have not been collected and tabulated for manyyears.METHODS:Information on tubal sterilizations from the National Hospital Discharge Survey and the National Survey of Ambulatory Surgery was analyzed to estimate the number and characteristics of women having a tubal sterilization procedure in the United States during the period 1994-1996 and the resulting rates of tubal sterilization. These results were compared with those of previous studies to examine trends in clinical setting, in the timing of the procedure and in patient characteristics.RESULTS:In 1994-1996, more than two million tubal sterilizations were performed, for an average annual rate of 1 1.5 per 1,000 women; half were performed postpartum and half were interval procedures (i. e., were unrelated by timing to a pregnancy). All postpartum procedures were performed during inpatient hospital stays, while 96% of interval procedures were outpatient procedures. Postpartum sterilization rates were higher than interval sterilization rates among women 20-29 years of age; interval sterilization procedures were more common than postpartum procedures at ages 35-49. Sterilization rates were highest in the South. For postpartum procedures, private insurance was the expectedprimary source of payment for 48% and Medicaid was expected to pay for 41 %; for interval sterilization procedures, private insurance was the expected primary source of payment for 68% and Medicaid for 24%.CONCLUSIONS:Outpatient tubal sterilizations andprocedures using laparoscopy have increased substantially since the last comprehensive analysis of tubal sterilization in 1987, an indication of the effect of technical advances on the provision of this service. Continued surveillance of both inpatient and outpatient procedures is necessary to monitor the role of tubal sterilization in contraceptive practice.
The long tradition of using photographs in population research appears to be almost completely lost. Widely used in the early decades of the last century population specialists have avoided photographs to appear more scientific. However examining the work of social scientists who used photography to study population-related issues in the 1930s gives a sense of what has been lost as well as what can be gained from greater use of photographs as research tools. It is noted that photographs should be used as data in family planning (FP) and reproductive health research and as illustrations in publications and on Web sites. Reviving the use of photographs would help researchers better understand and more easily explain numerous aspects of health and FP services. Given the availability of a range of modern technologies researchers should begin collecting photographic evidence and journals such as Family Planning Perspectives should publish their findings.
Adigest that appeared recently in Family Planning Perspectives [A first pregnancy may be difficult to achieve after long-term use of an IUD, 2001, 33(4):181–182] summarizes at length and with accuracy a report by Helen Doll and coauthors that was originally published in the British Journal of Obstetrics and Gynaecology.1 That report concluded that “long term use of an intrauterine device by a nulliparous woman increases the risk of impairment of fertility to a clinically important extent.” Because readers of Family Planning Perspectives may have limited access to articles and letters appearing in British journals, they would likely not be aware of our reanalysis of the data and our challenge to the authors’ interpretation of their results.2 Specifically, the researchers “assessed fertility by calculating the time taken from stopping contraception to plan pregnancy until the delivery at term.” Their finding is entirely statistical, and we reached quite different statistical conclusions in our reanalysis. We used the number of women still at risk, as shown by the authors in their tables, to recalculate the rates and to estimate standard errors. We found no statistically significant difference between long-term IUD users and long-term pill users at any time in the proportions of women with no delivery, nor was there a significant age difference. Indeed, we found a significant difference between short-term use of IUDs and long-term use through 30 months, but there was no difference thereafter in the proportion who did not give birth. Further, there was a significant difference in age between shortterm IUD users and long-term users (p=.035). The longer-term IUD users were older when they discontinued use to plan a pregnancy. Long-term IUD users were significantly older than were barrier method users (p=.000004), whom the authors did not analyze by use-duration. Through 30 months after discontinuation, long-term IUD users had significantly higher rates of having had no birth, but by 36 months and thereafter, there was no statistically significant difference in these rates. Tables 3 and 4 of the original paper showed that being 35 or older at discontinuation for planned pregnancy was the strongest factor adversely associated with having a term birth. IUD users represented fewer than one-third of all women studied, but were 50% of women aged 35 and older and were 46% of women aged 30–34 at discontinuation. What Doll and her coauthors show is that younger nulliparous women conceive rather speedily, regardless of the contraceptive method they had been using previously. They have not demonstrated differences by contraceptive method in the proportions of women who have not had a child at three years or thereafter, nor have they shown any differences between IUD users and pill users. Moreover, they also have not demonstrated that the higher proportions of long-term IUD users who in the first 12–30 months following discontinuation have not had a child can be attributed to disease or to disease sequelae. Partnership dissolution (either marital or nonmarital) is not addressed, nor are other social circumstances, including changes of mind, which might well affect women who have remained childless through their early 30s. The data strongly suggest that whatever differences exist in the recovery of fertility in this study among former barrier method users and former pill and IUD users are associated with age. The conclusion that nulliparous women should avoid long-term IUD use is therefore unwarranted by these data.
CONTEXTWhile a number of studies have examined the association between individuals' characteristics and their contraceptive use, few studies have examined the influence of partners' characteristics on individuals' contraceptive use.METHODSUsing nationally representative data from the National Longitudinal Study of Adolescent Health, multiple logistic analyses were conducted to identify associations between the demographic characteristics of adolescents' heterosexual partners and adolescents' use of condoms or other contraceptive methods.RESULTSThe partners of white and black adolescents were likely to be similar to them, while the partners of Latino adolescents and of adolescents of "other" race or ethnicity were more likely to be of a different racial or ethnic group. Differences in age between adolescents and their partners were notable in all racial and ethnic groups. As adolescents age, the characteristics of their partners become more heterogeneous. The less similar adolescents and their partners are to one another--whether because of a difference in age, grade or school--the less likely adolescents are to use condoms and other contraceptive methods.CONCLUSIONSMany adolescents have relationships with partners whose characteristics differ from theirs and with whom they are less likely to use condoms or other contraceptive methods. This behavior is more common as adolescents grow older. To provide appropriate counseling, sexuality educators and family planning providers need to consider the ways in which adolescents' relationships change as they age and discuss with them the dynamics of relationships involving partners who differ in age or other characteristics.
for the workshop. In addition, a panel of 28 people was chosen from a spectrum of backgrounds and ideologies to help craft the report. The workshop itself was at- tended by 180 interested individuals. The ground rules for the report were made clear from the outset. The panel ex- amined only those peer-reviewed, pub- lished articles included in the presentations at the workshop. This limitation ensured that the independent scientific evaluation that occurs prior to publication was in- herent in all of the data considered. While this approach allowed a certain quality control, it meant that several bodies of data (e.g., those available but unpublished, or those published but deemed unacceptable by the speakers) were not included in the full set of information considered by the panel. Nonetheless, an impressive array of 138 peer-reviewed articles that had been published by the time of the workshop were the basis for the NIH report. The report was limited to evaluating the effectiveness of male latex condoms used during penile-vaginal intercourse. It ex- amined evidence on eight STIs—HIV, gon- orrhea, chlamydia, syphilis, chancroid, tri- chomoniasis, genital herpes and genital human papillomavirus. The evaluation methodology was extensive, considering both the efficacy (ideal use) and the effec- tiveness (typical use) of the condom. The quality of the study design, the ascertain- ment of exposure (e.g., consistent condom use), the laboratory measures of outcome (e.g., STIs) and the adequacy of statistical analytic approaches were examined.
CONTEXT:Little is known about the factors associated with the choice of female-controlled, over-the-counter barrier contraceptive methods among women and their male sexual partners.METHODS:Predictors of method choice were assessed following an educational presentation on contraceptive use and risk reduction among 510 sexually active females aged 15-30 who were recruited in the San Francisco Bay Area. In addition, the primary partners of 160 of these women participated in the surveyRESULTS:Twenty-two percent of women who enrolled in the study alone, 25% of those who enrolled with their main partner and 18% of these male partners chose female-controlled, over-the-counter barrier methods alone. The strongest predictor of this choice was current use of a hormonal contraceptive both for women who participated in the study on their own (odds ratio, 2.1) and for those who enrolled their partner in the study (odds ratio, 6.3). Female-controlled methods were also chosen significantly more often by teenagers than by older women; for example, among those who enrolled with a male partner, the odds ratio for selection of a female-controlled barrier method by women younger than 18 was 6.0. Among women who enrolled without a partner, those who had had multiple partners in the previous six months and those who were current users of male condoms were less likely to choose female-controlled methods (odds ratios, 0.7 and 0.5, respectively).CONCLUSIONS:Although the majority of participants did not choose female-controlled, over-the-counter barrier methods without also choosing male condoms, such female-controlled methods appear to offer an acceptable alternative for prevention of sexually transmitted infections. They may be a particularly attractive option for individuals using hormonal contraceptives and for teenage women.
