Gender inequality and the ‘East-West’ divide in contraception: An analysis at the individual, the couple, and the country level

Association between women's empowerment and demand for family planning satisfied among Christians and Muslims in multireligious African countries

BACKGROUND

Although the levels of demand for family planning satisfied (DFPS) have increased in many countries, cultural norms remain a significant barrier in low- and middle-income countries. In the context of multireligious African countries, our objective was to investigate intersectional inequalities in DFPS by modern or traditional contraceptives according to religion and women's empowerment.

METHODS

Analyses were based on Demographic and Health Surveys carried out between 2010 and 2021 in African countries. Countries with at least 10% of Muslims and Christians were selected to analyse inequalities in family planning. The religious groups were characterised by wealth, area of residence, women's age and women's empowerment. The mean level of empowerment was estimated for each religious group, and multilevel Poisson regression was used to assess whether DFPS varied based on the level of women's empowerment among Muslims and Christians.

RESULTS

Our study sample of 14 countries comprised 35% of Muslim and 61% of Christian women. Christians had higher levels of empowerment across all three domains compared with Muslims and women with no/other religion. DFPS was also higher among Christians (57%) than among Muslims (36%). Pooled analysis indicated a consistent association between DFPS and women's empowerment, with higher prevalence ratios among Muslims than Christians, especially in the decision-making domain.

CONCLUSIONS

The gap between Muslims and Christians in DFPS significantly reduced as the level of empowerment increased. It highlights the importance of understanding and addressing cultural factors sensibly and respectfully to satisfy the demand for family planning services.

Relationship between classic indicators of health behaviour and contraceptive choices in women in Flanders

BACKGROUND

In this study we shed light on ongoing trends in contraceptive use in Flanders (Belgium). Building on the fundamental cause theory and social diffusion of innovation theory, we examine socio-economic gradients in contraceptive use and the relationship to health behaviours.

METHODS

Using the unique and recently collected (2020) ISALA data, we used multinomial logistic regression to model the uptake of contraceptives and its association to educational level and health behaviour (N:4316 women).

RESULTS

Higher educated women, and women with a healthy lifestyle especially, tend to use non-hormonal contraceptives or perceived lower-dosage hormonal contraceptives that are still trustworthy from a medical point of view. Moreover, we identified a potentially vulnerable group in terms of health as our results indicate that women who do not engage in preventive health behaviours are more likely to use no, or no modern, contraceptive method.

DISCUSSION

The fact that higher educated women and women with a healthy lifestyle are less likely to use hormonal contraceptive methods is in line with patient empowerment, as women no longer necessarily follow recommendations by healthcare professionals, and there is a growing demand for naturalness in Western societies.

CONCLUSION

The results of this study can therefore be used to inform policy makers and reproductive healthcare professionals, since up-to-date understanding of women's contraceptive choices is clearly needed in order to develop effective strategies to prevent sexually transmitted infections and unplanned pregnancies, and in which women can take control over their sexuality and fertility in a comfortable and pleasurable way.

Widowhood status, morbidity, and mortality in India: evidence from a follow-up survey

A known health effect of widowhood is an increased mortality risk among surviving spouses, with gender- and age-specific observations. While morbidity conditions with socio-economic factors may exacerbate the effect of widowhood on mortality, no research has attempted to predict mortality among the widowed over the married population with the presence of morbidity in India. Thus, the present study concurrently examines marital status and health in the Indian setting, bringing substantial empirical evidence to explore the link between marital status, morbidity, and mortality. The study used prospective data from India Human Development Survey (IHDS) wave 1 (2004-2005) and wave 2 (2011-2012). In total, 82,607 individuals aged 25 years and above were considered for the analysis. To present the preliminary findings, descriptive statistics and bivariate analysis were used. Using multivariable logistic regression, the interaction effect of marital status and morbidity status was estimated to predict the likelihood of mortality. Across all socio-economic groups, widowed individuals reporting any morbidity had a higher mortality proportion than married people. Young widowers with any morbidity are more susceptible to increased mortality. Asthma among young widowers and cardiovascular diseases among elderly widowers significantly elevate the probability of mortality. However, older widowed women with diabetes had a lower probability of mortality than older married women with diabetes. The widowers' disadvantage in mortality and morbidity may be attributable to less care-receiving and the greater incidence of unhealthy lifestyle practices during the post-widowhood period, indicating the need for more research.

Couple communication and contraception use in urban Senegal

Objectives:

Couple communication about family planning has been shown to increase uptake of contraception. However, couple communication is often measured based solely on one partner’s report of communication. This research investigates the influence of couple-reported communication about family planning on current and future use of contraception using couple-level data.

Methods:

We used baseline data from the Measurement, Learning, and Evaluation (MLE) project collected through household surveys in 2011 from a cross-sectional representative sample of women and men in urban Senegal to conduct secondary data analysis. We used multivariable logit models to estimate the average marginal effects of couple communication about family planning on current contraception use and future intention to use contraception.

Results:

Couple communication about family planning reported by both partners was significantly associated with an increased likelihood of current use of contraception and with future intention to use contraception among non-contracepting couples. Couples where one partner reported discussing family planning had a 25% point greater likelihood of current contraception use than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 56% point greater likelihood of current contraception use, representing more than twice the effect size. Among couples not using contraception, couples where one partner reported discussing family planning had a 15% point greater likelihood of future intention to use contraception than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 38% point greater likelihood of future intention to use contraception.

Conclusion:

These findings underscore the importance of the inclusion of both partners in family planning programs to increase communication about contraception and highlight the need for future research using couple-level data, measures, and analysis.

Individual- and country-level correlates of female permanent contraception use in sub-Saharan Africa

Background

Female permanent contraception is a cost-effective contraceptive method that can help clients with the desire to limit childbearing achieve their reproductive intention. However, despite its benefits, the use of FPC remains low in sub-Saharan Africa (SSA), and limited studies have examined the correlates of its uptake. In this study, we assessed the individual- and country-level factors associated with the use of FPC among married or in-union women using modern contraceptive methods to limit childbearing in SSA.

Methods

This study was a secondary data analysis of individual- and country-level data obtained from the Demographic and Health Surveys (DHS) Program and three open data repositories. The study included 29,777 married or in-union women aged 15–49 years using modern contraceptive methods to limit childbearing from DHS conducted in 33 sub-Sahara African countries between 2010 and 2018. We performed descriptive statistics and fitted multilevel logistic regression models to determine the predisposing, enabling, and need factors associated with the use of FPC.

Results

Approximately 13% of the women used FPC. About 20% of the variance in the odds of using FPC was attributable to between-country differences. In the full model, the significant individual-level factors associated with the use of FPC compared with other modern contraceptive methods were: age (odds ratio [OR] = 1.10; 95%CI = 1.08–1.12), living children (OR = 1.11, 95%CI = 1.04–1.16), high household wealth (OR = 1.39, 95%CI = 1.18–1.64), rural residence (OR = 0.83, 95% CI = 0.71–0.97), joint contraceptive decision with partner (OR = 1.68, 95% = 1.43–1.99), contraceptive decision by partner and others (OR = 2.46, 95% = 1.97–3.07), and the number of living children less than the ideal number of children (OR = 1.40, 95%CI = 1.21–1.62). The significantly associated country-level factors were births attended by skilled health providers (OR = 1.03, 95%CI = 1.00–1.05) and density of medical doctors (OR = 1.37, 95%CI = 1.01–1.85).

Conclusions

Our results suggest that both individual- and country-level factors affect uptake of FPC in SSA. Increasing geographic, economic, and psychosocial access to FPC may improve its uptake in SSA.

Does gender equality and availability of contraception influence maternal and child mortality? A systematic review

BACKGROUND

Current global maternal and child health policies rarely value gender equality or women's rights and are restricted to policies addressing clinical interventions and family planning. Gender equality influences the knowledge, autonomy and utilisation of contraception and healthcare, thereby affecting maternal and child health. This systematic review aims to analyse the concurrent effect of gender equality and contraception on maternal and under-5 child mortality.

METHODS

A systematic review was conducted to investigate the current evidence. Studies were eligible if three themes-namely, indicators of gender equality (such as female education, labour force participation, gender-based violence), contraception, and maternal or child mortality-were present together in a single article analysing the same sample at the same time.

RESULTS

Even though extensive literature on this topic exists, only three studies managed to fit the selection criteria. Findings of two studies indicated an association between intimate partner violence (IPV) and infant mortality, and also reported that women's contraceptive use increased the risk of IPV. The third study found that the mother's secondary education attainment significantly reduced child mortality, while the mother's working status increased the odds of child mortality. The researchers of all included studies specified that contraceptive use significantly reduced the risk of child mortality.

CONCLUSION

Improvement in gender equality and contraception concurrently affect the reduction in child mortality. These findings provide strong support to address the research gaps and to include a gender equality approach towards maternal and child health policies.

Sexual function changes attributed to hormonal contraception use - a qualitative study of women experiencing negative effects

Objective: To increase the understanding of women who experience negative effects on sexual function when using hormonal contraception.Methods: We performed 24 in-depth interviews with women who had previously experienced negative sexual function effects while using hormonal contraceptives. The thematic analysis method was used.Results: 'After experience comes insight', 'Lubrication and desire go hand in hand', 'Mental wellbeing comes before desire' and 'The contraceptive counsellor potentially facilitates insight and decision-making' were the main themes found in the study.Conclusions: This selected group of women described lubrication difficulties and decreased sexual desire associated with both contraceptive use and the menstrual cycle. Contraceptive use became easier with age and with better understanding. The contraceptive counsellor could facilitate the process. Further choice between hormonal or non-hormonal contraceptive methods depended primarily on experienced adverse effects on mood, and secondarily on sexual function, weighed against the advantages or disadvantages experienced during the person's own menstrual cycle.

RISUG® as a male contraceptive: journey from bench to bedside

Even after decades of research men still lack reliable and reversible contraceptive methods comparable to female methods of contraception. Traditional methods of male contraception present a high failure rate and also involve high risk both when used for contraception and for protection against sexually transmitted diseases. Various chemical, hormonal, immunological, vas based and herbal methods of contraception have been examined by scientists world over during the past four decades. Among the possible lead approaches, exogenous hormonal contraception, either alone or in combination with progesterone or antiandrogen, is being viewed at low profile because of their insufficiency in inducing uniform suppression of spermatogenesis and steroid related long term complications. As an alternative to vasectomy, among various intravasal devices being examined, RISUG® (Reversible Inhibition of Sperm Under Guidance), a co-polymer of styrene and maleic anhydride offers long term contraception with safety, efficacy and it can be delivered by no-scalpel injection. Thus it is the only male contraceptive procedure currently under Phase- III Clinical Trial. The non-invasive reversal technique, successfully demonstrated in langur monkeys and functional reversal achieved with dimethyl sulphoxide (DMSO) and sodium bicarbonate (NaHCO3) in rats and rabbits with safety at F1 generation (first filial generation) have projected RISUG® as a better alternative to vasectomy. In this narrative review we revisit the long journey of RISUG® beginning with formulation on a bench towards reaching the market as a safe and effective contraceptive method, discussing various milestones and roadblocks of this expedition awaiting the mandatory regulatory clearance from the Government of India. Successful completion of ongoing phase III clinical trials with demonstration of reversal in human volunteers will give an indigenously developed male contraceptive to the world.

'It's just a very personal thing': contraceptive influences and decision making among women living in Italy

Objective: The purpose of the study was to assess contraceptive knowledge, perceptions and experiences among reproductive-aged women in Italy. Methods: As part of a larger mixed-methods study, researchers conducted 46 interviews (June-July 2017) with English-speaking women aged 18-45 living in or near Florence, Italy, who were using the Italian health care system. Researchers used grounded theory to explore women's contraceptive decision making and use. HyperRESEARCH software was used to aid data organisation and analysis. Researchers used a comparative method to contextualise data and identify emergent themes. Results: Participants illuminated knowledge gaps and misinformation about the efficacy and long-term health effects of hormonal contraceptive methods. Family, friends and health care providers influenced their contraceptive choices. Local family planning clinics (consultori) were cited as primary sources of contraceptive information, resources and access. Conclusion: Misinformation may contribute to the underuse of effective hormonal contraception in Italy. The study findings can inform practical recommendations to improve the dissemination of contraceptive information. Improved messaging strategies could address contraceptive concerns (e.g., hormonal effects) and knowledge gaps, which may improve hormonal contraceptive uptake.

Country-Level Gender Equality and Adolescents' Contraceptive Use in Europe, Canada and Israel: Findings from 33 Countries

CONTEXT

Although an association between gender equality and contraceptive use has been confirmed among adult samples, few studies have explored this relationship among adolescents. An examination of whether adolescents' contraceptive use is more prevalent in countries with higher levels of gender equality is needed to fill this gap.

METHODS

Nationally representative data from 33 countries that participated in the 2013-2014 Health Behaviour in School-Aged Children study and country-level measures of gender equality-using the 2014 Global Gender Gap Index-were analyzed. Multilevel multinomial logistic regression analyses were employed to assess associations between gender equality and contraceptive use (condom only, pill only and dual methods) at last intercourse as reported by 4,071 females and 4,110 males aged 14-16.

RESULTS

Increasing gender equality was positively associated with contraceptive use among both males and females. For every 0.1-point increase on the equality scale, the likelihood of condom use at last intercourse rose (odds ratio, 2.1 for females), as did the likelihood of pill use (6.5 and 9.6, respectively, for males and females) and dual method use (2.1 and 5.6, respectively). Associations with pill use and dual use remained significant after national wealth and income inequality were controlled for. Overall, associations were stronger for females than for males.

CONCLUSIONS

More research is needed to identify potential causal pathways and mechanisms through which gender equality and adolescents' contraceptive use may influence one another.

Associations between gender equality and health: a systematic review

This systematic review sought to evaluate the impact of gender equality on the health of both women and men in high-income countries. A range of health outcomes arose across the 48 studies included. Gender equality was measured in various ways, including employment characteristics, political representation, access to services, and with standard indicators (such as the Global Gender Gap Index and the Gender Empowerment Measure). The effects of gender equality varied depending on the health outcome examined, and the context in which gender equality was examined (i.e. employment or domestic domain). Overall, evidence suggests that greater gender equality has a mostly positive effect on the health of males and females. We found utility in the convergence model, which postulates that gender equality will be associated with a convergence in the health outcomes of men and women, but unless there is encouragement and support for men to assume more non-traditional roles, further health gains will be stymied.

Parental Gender Expectations by Socioeconomic Status and Nativity: Implications for Contraceptive Use

Parental gender expectations, which may be egalitarian or not, may vary by nativity and socioeconomic status. Parental gender expectations provide a model for children's gender role attitudes and could also have effects on reproductive health over the life course, including women's contraceptive choices. Yet, parental gender expectations are not often studied quantitatively. Using the National Longitudinal Study of Adolescent to Adult Health, we examine how parental gender expectations in the United States vary by immigrant generation and socioeconomic status, whether parental gender expectations in adolescence are associated with young women's contraceptive use, and if nativity moderates that relationship. Results show that parental gender expectations vary significantly by immigrant generation and parental socioeconomic status. Both first and second generation women are significantly less likely to have lived in households with equal gender expectations compared to the third generation. Higher socioeconomic status is associated with equal gender expectations. Among participants from households with equal gender expectations, the second generation is more likely than the third generation is to use a male-controlled contraceptive method versus no method. Using a nationally representative sample, our study demonstrates that parental gender expectations vary by nativity and by the socioeconomic context of the family in which they are embedded as well as have a unique effect on the contraceptive behavior of second generation women.