Adolescent girls with illegally induced abortion in Dar es Salaam: the discrepancy between sexual behaviour and lack of access to contraception

The role of partners, parents and friends in shaping young women's reproductive choices in Peri-urban Nairobi: a qualitative study

BACKGROUND

Contraceptive use among young women in Nairobi remains low despite high general knowledge of family planning (FP) methods. This paper draws on social norms theory to explore the role of key influencers (partners, parents and friends) in women's FP use and how women anticipate normative reactions or sanctions.

METHODS

A qualitative study with 16 women, 10 men and 14 key influencers across 7 peri-urban wards in Nairobi, Kenya. Interviews were conducted during the COVID-19 pandemic in 2020 by phone. A thematic analysis was conducted.

RESULTS

Women identified parents, specifically mothers, aunts, partners, friends and healthcare workers as key influencers on FP. Their interactions with these key influencers varied based on trust, the information they needed about FP, and whether they perceived a key influencer to perpetuate or challenge existing social norms on FP. Mothers were perceived to understand the social risks of using FP and thus could advise on discreet FP use, and aunts were trusted and approachable sources to impartially describe the benefits and drawbacks of FP. Although women identified partners as key FP decision makers, they were cognisant of possible power imbalances affecting a final FP choice.

CONCLUSIONS

FP interventions should consider the normative influence key actors have on women's FP choices. Opportunities to design and deliver network-level interventions which seek to engage with social norms surrounding FP in order to challenge misconceptions and misinformation among key influencers should be explored. Intervention design should consider dynamics of secrecy, trust and emotional closeness that mediate discussions of FP to address changing norms. Further training to change norms held by healthcare providers about why women, in particular unmarried young women, access FP should be provided to reduce barriers for FP access.

Contraceptive Conversations among Adolescent Girls and Young Women and Their Partners, Peers, and Older Female Family Members in Lilongwe, Malawi: A QualitativeAnalysis

In sub-Saharan Africa, adolescent girls and young women (AGYW) have high levels of unmet need for contraception, particularly those who are unmarried or nulliparous. Conversations with partners, peers, and family members influence AGYW contraceptive decision-making yet little is known about conversation content and impact or how they vary by relationship status and parity. This paper draws on qualitative data from 60 AGYW (aged 15-24) participating in a sexual and reproductive health study in Malawi to examine contraceptive conversation patterns among participants and their social ties. AGYW's relationship status and parity influenced whether they talked about contraceptives, who they talked to about contraceptives, and the type of contraceptives that were endorsed during conversations. Unmarried and nulliparous AGYW were less likely to discuss contraceptives with all social ties and when conversations occurred, norms and misinformation regarding nonbarrier methods were reinforced, and condoms were largely prescribed. Conversations with intimate partners often provided permission for contraceptive use while conversations with peers and older women in the family provided information on contraceptive methods. Our results highlight the unique roles that social ties play in AGYW contraceptive decision-making and suggest that existing contraceptive conversation patterns might exclude unmarried, nulliparous AGYW from accurate and comprehensive contraceptive information and options.

An evolution of socioeconomic related inequality in teenage pregnancy and childbearing in Malawi

BACKGROUND

Teenage pregnancies and childbearing are important health concerns in low-and middle-income countries (LMICs) including Malawi. Addressing these challenges requires, among other things, an understanding of the socioeconomic determinants of and contributors to the inequalities relating to these outcomes. This study investigated the trends of the inequalities and decomposed the underlying key socioeconomic factors which accounted for the inequalities in teenage pregnancy and childbearing in Malawi.

METHODS

The study used the 2004, 2010 and 2015-16 series of nationally representative Malawi Demographic Health Survey covering 12,719 women. We used concentration curves to examine the existence of inequalities, and then quantified the extent of inequalities in teenage pregnancies and childbearing using the Erreygers concentration index. Finally, we decomposed concentration index to find out the contribution of the determinants to socioeconomic inequality in teenage pregnancy and childbearing.

RESULTS

The teenage pregnancy and childbearing rate averaged 29% (p<0.01) between 2004 and 2015-16. Trends showed a "u-shape" in teenage pregnancy and childbearing rates, albeit a small one (34.1%; p<0.01) in 2004: (25.6%; p<0.01) in 2010, and (29%; p<0.01) in 2016. The calculated concentration indices -0.207 (p<0.01) in 2004, -0.133 (p<0.01) in 2010, and -0.217 (p<0.01) in 2015-16 indicated that inequality in teenage pregnancy and childbearing worsened to the disadvantage of the poor in the country. Additionally, the decomposition exercise suggested that the primary drivers to inequality in teenage pregnancy and child bearing were, early sexual debut (15.5%), being married (50%), and wealth status (13.8%).

CONCLUSION

The findings suggest that there is a need for sustained investment in the education of young women concerning the disadvantages of early sexual debut and early marriages, and in addressing the wealth inequalities in order to reduce the incidences of teenage pregnancies and childbearing.

A scoping review on sexual and reproductive health behaviors among Tanzanian adolescents

Background

There is wide variation among societies in profiles of adolescent health and behaviors, but they all experience sexual and reproductive health as a major challenge. However, adolescents in middle- and low-income countries are of particular concern, as it is the case in Tanzania, where limited social, educational, and health services contribute to make them victims of unwanted pregnancies, unsafe abortion, and sexually transmitted infections including HIV. Thus, we undertook a descriptive systematic scoping review of the available published information on sexual and reproductive health among Tanzanian adolescents.

Methods

We performed a scoping review to collect and analyze observational data on sexual and reproductive health behaviors among Tanzanian adolescents. Publications were identified using PubMed®, Scopus®, Web of Science™, and Cochrane Library electronic databases from 2000 to December 2017. A protocol was defined to identify relevant studies. We included original observational studies conducted in Tanzania and published in English, both quantitative and qualitative, involving adolescents (10 to 19 years old), and that considered at least one of the following items: condom use, number of sexual partners, sexual debut, contraceptive prevalence, sexually transmitted infections, unwanted pregnancies, abortion, or knowledge about reproductive health. All included articles were coded according to relevant exposures or outcomes and subsequently analyzed to assess frequencies.

Results

After screening for inclusion criteria, 13 publications were included in the datasheet developed to record the findings. Overall, the publications revealed that adolescents tend to be sexually active, with high rates of early sexual debut, have multiple sexual partners, and a limited use of condom and contraceptives. Sexual coercion and transactional sex were also frequent. Only one study addressed pregnancy as an outcome, and a single study looked at the relevant health services. No study was retrieved describing the frequency of unsafe abortion.

Conclusion

Adolescents engage in high-risk sexual behaviors and experience its adverse consequences. It is essential to collect more information, but the existing evidence supports a need for improving provision of sexual and reproductive health services among Tanzanian adolescents.

Predictors of Unsafe Induced Abortion among Women in Ghana

Background

Unsafe induced abortion is a major contributor to maternal morbidity and mortality in Ghana.

Objective

This study aimed to explore the predictors of unsafe induced abortion among women in Ghana.

Methods

The study used data from the 2017 Ghana Maternal Health Survey. The association between women's sociodemographic, obstetric characteristics, and unsafe induced abortion was explored using logistic regression. The analysis involved a weighted sample of 1880 women aged 15-49 years who induced abortion in the period 2012-2017. Analysis was carried out using STATA/IC version 15.0. Statistical significance was set at p <0.05.

Results

Of the 1880 women, 64.1% (CI: 60.97-67.05) had an unsafe induced abortion. At the univariate level, older women (35-49 years) (odds ratio=0.50, 95% CI: 0.28-0.89) and married women (odds ratio=0.61, 95% CI:0.44-0.85) were less likely to have an unsafe induced abortion while women who did not pay for abortion service (odds ratio=4.44, 95% CI: 2.24-8.80), who had no correct knowledge of the fertile period (odds ratio =1.47, 95% CI: 1.10-1.95), who did not know the legal status of abortion in Ghana (odds ratio =2.50, 95% CI: 1.68-3.72) and who had no media exposure (odds ratio =1.34, 95% CI: 1.04-1.73) had increased odds for an unsafe induced abortion. At the multivariable level, woman's age, payment for abortion services, and knowledge of the legal status of abortion in Ghana were predictors of unsafe induced abortion.

Conclusion

Induced abortion is a universal practice among women. However, unsafe abortion rate in Ghana is high and remains an issue of public health concern. We recommend that contraceptives and safe abortion services should be made available and easily accessible to women who need these services to reduce unwanted pregnancies and unsafe abortion rates, respectively, in the context of women's health. Also, awareness has to be intensified on abortion legislation in Ghana to reduce the stigma associated with abortion care seeking.

Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: a systematic review

Background

Adolescents face significant barriers to contraception access and utilization that result in adverse health effects of early pregnancy and childbirth. Unsafe abortions continue to occur partly due to failure to prevent pregnancies, with Sub-Saharan Africa contributing the most significant burden of all unsafe abortions among young people globally, of which a quarter occurs in those aged 15–19 years. We aimed to conduct a systematic review of the contraceptive and abortion knowledge, attitudes and practices of adolescents in low and middle-income countries to increase the understanding of the sexual and reproductive health dynamics that they face.

Methods

Literature searches from 6 databases; PubMed, Science Direct, Google Scholar, BioMed Central, CINAHL, MEDLINE, were conducted, covering the period from 1970 to 2016 and concerning the adolescents aged 15–19 years and 21 studies were read and analyzed using thematic analysis.

Results

Limited knowledge about sexual and reproductive health among adolescents was a significant cause of reduced access to contraception and safe abortion services, especially among unmarried adolescents. Reduced access to reproductive health services for some resulted in extreme methods of contraception and abortion such as the use of battery acid and crushed bottles. Despite all adolescents having limited access to information and services, girls faced more consequences such as being blamed for pregnancy or dealing with the effects of unsafe abortions. Parents, health workers, and teachers were cited as trusted sources of information but often received the most information from peers and other family members instead, and the girls mostly confided in their aunties, cousins and peers while the boys resorted to peers, media and even pornography.

Conclusion

The reported observations suggest severe limitations in the access to safe and effective methods of contraception and safe abortion services. There is a need for an urgent response in reducing the “unmet needs” for contraception and to improve access to contraception, abortion information, and services in this group. Interventions which target the involvement of parents and teachers should be considered, to carry one wholesome message to the adolescents.

Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda

BACKGROUND

Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries.

METHODS

We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach.

RESULTS

Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda.

CONCLUSIONS

Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.

Sociocultural factors contributing to teenage pregnancy in Zomba district, Malawi

This study explores sociocultural and other risk factors associated with unplanned teenage pregnancy in Zomba district of Malawi. Data were obtained from 505 participants under the age of 20 years using a questionnaire administered through face-to-face interviews held at five antenatal clinics. The data were analysed using descriptive statistics, frequency tables and chi-square analysis which allowed comparative understanding of the sociocultural risk factors for planned and unplanned teenage pregnancy in Zomba district. The findings revealed that teenage pregnancy is a major health and social problem. Over 76% of the teenage respondents in the study had experienced unplanned pregnancy. Among the prominent factors that stood out in the analysis for this high rate of teenage pregnancy were early sex and marriage, low contraceptive use, low educational levels, low socio-economic status, lack of knowledge of reproductive and sexual health, gender inequity, and physical/sexual violence. The consequences on teenage mothers of unplanned pregnancy have been tragic and have compromised their physical, psychological and socioeconomic wellbeing, not just on them but also their families and society at large. The findings point to the need for a multi-sectoral approach to tackle the problem on teenage pregnancy in this district, and likely throughout Malawi.

Sociocognitive Predictors of Condom Use and Intentions Among Adolescents in Three Sub-Saharan Sites

Many HIV intervention programs in sub-Saharan Africa have applied social cognitive theories such as the theory of planned behavior. However, a recent sub-Saharan African review was unable to show increased effectiveness for theory-based interventions. This study assessed whether the predictive value of attitudes, subjective norms, self-efficacy, and intention was similar to studies in Europe and the U.S., and whether there were differences between three sub-Saharan sites. Longitudinal multigroup structural equation modeling was used to assess whether attitudes, subjective norms, and self-efficacy predicted condom use intentions and condom use (after 6 months) among adolescents in three sites, namely Cape Town (South Africa; N = 625), Dar es Salaam (Tanzania; N = 271), and Mankweng (South Africa; N = 404). Condom use intentions were predicted by subjective norms and self-efficacy in all three sites. Attitudes were not related to intentions in Dar es Salaam and were moderately related to intentions in Cape Town and Mankweng. The proportions of explained variance in intentions and behavior were decent (37-52 and 9-19%, respectively). Although significant differences in predictive value were found between sites and in comparison to European and U.S. studies, intentions could adequately be explained by attitudes, subjective norms, and self-efficacy. However, the limited proportions of variance in behavior explained by intentions could signify the importance of contextual and environmental factors. Future studies are recommended to use an integrative approach that takes into account both individual and contextual factors, as well as social and environmental differences.

Barriers to access reproductive health care for pregnant adolescent girls: a qualitative study in Tanzania

AIMS

In Tanzania, approximately 25% of adolescents give birth and 50% more become sexually active during adolescence. We hypothesised that reproductive health education and services for adolescent girls are inaccessible and conducted this study to gain insights into their perceptions of sexually transmitted infections (STIs) and barriers to reproductive health service utilisation in rural Mwanza, Tanzania.

METHODS

We conducted nine focus groups among pregnant adolescents aged 15-20 years. Data were transcribed, translated and coded for relevant themes using NVivo10 software for qualitative data analysis.

RESULTS

Most participants were aware of the dangers of STIs to themselves and their unborn babies, but did not perceive themselves as at risk of acquiring STIs. They viewed condoms as ineffective for preventing STIs and pregnancies and unnecessary for those in committed relationships. Stigma, long waiting times, and lack of privacy in the clinics discouraged adolescent girls from seeking reproductive health care.

CONCLUSION

Reproductive health care for adolescent girls who are not pregnant is practically nonexistent in Tanzania. Healthcare access for pregnant young women is also limited. Targeted changes to increase clinic accessibility and to provide reproductive health education to all rather than only pregnant women have the potential to address these gaps.

Predictors of abortions in Rural Ghana: a cross-sectional study

Background

Abortion continues to be used as a method of family planning by many women. The complications of unsafe abortions are a major contributor to maternal mortality in sub-Saharan Africa, including Ghana. This study explored the influence of socio-demographic characteristics on abortions in 156 communities within the Kintampo Health and Demographic Surveillance System (KHDSS) area located in the middle part of Ghana.

Methods

A survey on Sexual and Reproductive Health among a representative sample of females aged 15–49 years was conducted in 2011. They were asked about the outcome of pregnancies that occurred between January 2008 and December 2011. Data on their socio-demographic characteristics including household assets were accessed from the database of the KHDSS. Univariate and multivariate random effects logistic regression models were used to explore the predictors of all reported cases of abortion (induced or spontaneous) and cases of induced abortion respectively.

Results

A total of 3554 women were interviewed. Of this total, 2197 women reported on the outcomes of 2723 pregnancies that occurred over the period. The number of all reported cases of abortions (induced and spontaneous) and induced abortions were 370 (13.6%) and 101 (3.7%) respectively.

Unmarried women were more likely to have abortion as compared to married women (aOR = 1.77, 95% CI [1.21-2.58], p = 0.003). Women aged 20–29 years were 43% less likely to have abortion in comparison with those within the ages 13–19 years (aOR = 0.57, 95% CI [0.34-0.95], p = 0.030). Women with primary, middle/junior high school (JHS) and at least secondary education had higher odds of having abortion as compared to women without education. Compared with the most poor women, wealthiest women were three-fold likely to have abortion.

Unmarried women had higher odds of having induced abortion as compared to married women (aOR = 7.73, 95% CI [2.79-21.44], p < 0.001). Women aged 20–29 years, 30–39 years and 40–49 years were less likely to have induced abortion as compared to those 13–19 years of age.

Conclusion

Extra efforts are needed to ensure that family planning services, educational programs on abortion and abortion care reach the target groups identified in this study.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1572-1) contains supplementary material, which is available to authorized users.

Do natural methods count? underreporting of natural contraception in urban Burkina Faso

Natural methods of contraception were widely used in developed countries until the late 1960s to space and limit childbirth. In France, when the first contraceptive surveys were conducted, researchers noticed that the use of natural methods was underreported, and questions to correct for this bias were subsequently added. The Demographic and Health Surveys do not currently include questions specific to natural methods. We added such questions to the standard DHS question regarding current contraceptive use when we conducted the Health and Demographic Surveillance System of Ouagadougou (2010 Ouaga HDSS) health survey in Burkina Faso among 758 women aged 15-49. Doing so enabled us to find a notable increase in the proportion of women in union who reported practicing contraception: 58 percent, compared with 38 percent in Ouagadougou in the 2010 Burkina Faso DHS. Thirty-two percent of women reported using modern medical methods or condoms in both surveys, but use of natural methods was much greater in the 2010 Ouaga HDSS health survey (26 percent) than in the 2010 Burkina Faso DHS (5 percent). Many women classified as having unmet need for family planning in Ouagadougou by the DHS data are in fact users of natural methods. Additional questions that would measure use of natural methods more completely should be tested in different settings.

Perception of susceptibility to the negative outcomes associated with unprotected sex among University of Venda students

Objectives: The purpose of this study was to determine the perception of University of Venda students on their susceptibility to the negative outcomes associated with unprotected sex.

Methods: This cross sectional study involved 408 (206 females and 202 males) University of Venda students residing within the university campus. Simple and systematic sampling methods were used to select participants. A 4-likert scaled self-administered questionnaire was used for data collection and a cut-off point of 75% of the total scores was used as criteria for assessing perception.

Results: Majority (90.90%) of the participants understood the magnitude and problems posed by HIV and other sexually transmitted infection in the society, 94.60% believe that anyone can be infected with HIV or fall pregnant when exposed to unprotected sex. Majority (87.30%) believed that alcohol consumption while engaging in sexual activities increases the chances of being infected with HIV, other STI or falling pregnant, 92.40% believed that having multiple sexual partnerships increases the risk of being infected with HIV and other sexually transmitted infections. Eighty six percent of participants agreed or strongly agreed that pregnancy could occur with one sexual intercourse in a month and only 68.45% of the participants believed that practising oral sex could expose them to HIV infection (with no significant difference between male and female).

Conclusion: Majority of the students showed high perception regarding their susceptibility to the negative outcomes associated with unprotected sex, especially when they consume alcohol while engaging in sexual activities and when having multiple sexual partnerships. Contrastingly, the students demonstrated low perception regarding susceptibility to HIV transmission through the practice of oral sex. There is a need to create awareness on the dangers posed by the practise of oral sex.

An exploration of knowledge, attitudes and behaviours of young multiethnic Muslim-majority society in Malaysia in relation to reproductive and premarital sexual practices

BACKGROUND

The increasing trend of premarital sexual experience and unintended pregnancies in Malaysia warrants sustained and serious attention. The sensitivities of sex-related issues in a Muslim-majority country create various types of barriers to sexual and reproductive health information, support and practices. This study aims to gain understanding of knowledge, attitudes and behaviours of young women in Malaysia concerning reproductive, contraception and premarital sexual practices.

METHODS

A cross-sectional study was performed, using an anonymous self-administered questionnaire carried out among 1695 female university students in a public university in Malaysia.

RESULTS

Respondents had low scores for knowledge of reproduction and pregnancy (median=4, of maximum score 10), contraceptive uses (median=6, of maximum score 16) and contraceptive availability (median=3, of maximum score 13). The majority of women surveyed do not have liberal values in relation to premarital sexual behaviour (median=37, of maximum 40); higher scores on this scale corresponded to opposing premarital sex. The multivariate analyses showed that ethnic group was the strongest correlate of knowledge and attitude scores; being of Malay Muslim ethnicity was associated significantly with lower knowledge scores and premarital sex permissiveness. Other significant correlates were year of study, maternal occupational groups, level of religious faith, dating status and urban-rural localities. Level of premarital sex permissiveness was inversely correlated with reproduction and pregnancy knowledge score, and contraceptive knowledge scores.

CONCLUSION

Reproductive health knowledge and attitudes were intricately linked to religious values and cultural norms differences surrounding sexual issues.

Evaluation of a reproductive health awareness program for adolescence in urban Tanzania--a quasi-experimental pre-test post-test research

BACKGROUND

Sub-Saharan Africa is among the countries where 10% of girls become mothers by the age of 16 years old. The United Republic of Tanzania located in Sub-Saharan Africa is one country where teenage pregnancy is a problem facing adolescent girls. Adolescent pregnancy has been identified as one of the reasons for girls dropping out from school. This study's purpose was to evaluate a reproductive health awareness program for the improvement of reproductive health for adolescents in urban Tanzania.

METHODS

A quasi-experimental pre-test and post-test research design was conducted to evaluate adolescents' knowledge, attitude, and behavior about reproductive health before and after the program. Data were collected from students aged 11 to 16, at Ilala Municipal, Dar es Salaam, Tanzania. An anonymous 23-item questionnaire provided the data. The program was conducted using a picture drama, reproductive health materials and group discussion.

RESULTS

In total, 313 questionnaires were distributed and 305 (97.4%) were useable for the final analysis. The mean age for girls was 12.5 years and 13.2 years for boys. A large minority of both girls (26.8%) and boys (41.4%) had experienced sex and among the girls who had experienced sex, 51.2% reported that it was by force. The girls' mean score in the knowledge pre-test was 5.9, and 6.8 in post-test, which increased significantly (t=7.9, p=0.000). The mean behavior pre-test score was 25.8 and post-test was 26.6, which showed a significant increase (t=3.0, p=0.003). The boys' mean score in the knowledge pre-test was 6.4 and 7.0 for the post-test, which increased significantly (t=4.5, p=0.000). The mean behavior pre-test score was 25.6 and 26.4 in post-test, which showed a significant increase (t=2.4, p=0.019). However, the pre-test and post-test attitude scores showed no statistically significant difference for either girls or boys.

CONCLUSIONS

Teenagers have sexual experiences including sexual violence. Both of these phenomena are prevalent among school-going adolescents. The reproductive health program improved the students' knowledge and behavior about sexuality and decision-making after the program for both girls and boys. However, their attitudes about reproductive health were not likely to change based on the educational intervention as designed for this study.

Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research

Background

Improving the reproductive health of young women in developing countries requires access to safe and effective methods of fertility control, but most rely on traditional rather than modern contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review of qualitative research to examine the limits to modern contraceptive use identified by young women in developing countries. Focusing on qualitative research allows the assessment of complex processes often missed in quantitative analyses.

Methods

Literature searches of 23 databases, including Medline, Embase and POPLINE^®, were conducted. Literature from 1970–2006 concerning the 11–24 years age group was included. Studies were critically appraised and meta-ethnography was used to synthesise the data.

Results

Of the 12 studies which met the inclusion criteria, seven met the quality criteria and are included in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to 149 young women (age range 13–19 years). Four of the studies were urban based, one was rural, one semi-rural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility. Although often more accessible, and sometimes more attractive than hormonal methods, condom use was limited by association with disease and promiscuity, together with greater male control. As a result young women often relied on traditional methods or abortion. Although the review was limited to five countries and conditions are not homogenous for all young women in all developing countries, the overarching themes were common across different settings and contexts, supporting the potential transferability of interventions to improve reproductive health.

Conclusion

Increasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges involved.

Risky sexual practices among youth attending a sexually transmitted infection clinic in Dar es Salaam, Tanzania

Background

Youth have been reported to be at a higher risk of acquiring STIs with significant adverse health and social consequences. Knowledge on the prevailing risky practices is an essential tool to guide preventive strategies.

Methods

Youth aged between 18 and 25 years attending an STI clinic were recruited. Social, sexual and demographic characteristics were elicited using a structured standard questionnaire. Blood samples were tested for syphilis and HIV infections. Urethral, high vaginal and cervical swabs were screened for common STI agents.

Results

A total of 304 youth were studied with mean age of 21.5 and 20.3 years for males and females respectively. 63.5% of youth were seeking STI care. The mean age of coitache was 16.4 and 16.2 years for males and females respectively. The first sexual partner was significantly older in females compared to male youth (23.0 vs 16.8 years) (p < 0.01). 93.2% of male youth reported more than one sexual lifetime partner compared to 63.0% of the females. Only 50% of males compared to 43% of females had ever used a condom and fewer than 8.3% of female youth used other contraceptive methods. 27.1% of pregnancies were unplanned and 60% of abortions were induced. 42.0% of female youth had received gifts/money for sexual favours. The HIV prevalence was 15.3% and 7.5% for females and males respectively. The prevalence of other STIs was relatively low. Among male youth, use of alcohol or illicit drugs was associated with increased risk of HIV infection. However, the age of sexual initiation, number of sexual partners or the age of the first sexual partner were not associated with increased risk of being HIV infected.

Conclusion

Most female youth seen at the STI clinic had their first sexual intercourse with older males. Youth were engaging in high risk unprotected sexual practices which were predisposing them to STIs and unplanned pregnancies. There is a great need to establish more youth-friendly reproductive health clinics, encourage consistent and correct use of condoms, delay in sexual debut and avoid older sexual partners in females.

Medium and long-term adherence to postabortion contraception among women having experienced unsafe abortion in Dar es Salaam, Tanzania

Background

Postabortion contraceptive service is considered an effective means in addressing the problem of unsafe abortion; in spite this fact this component remains one of the weakest parts of postabortion care. In this context, the paper aims to describe the impact of a postabortion contraceptive service intervention among women admitted with complications from unsafe abortions and to explore the women's long-term contraceptive adherence.

Methods

392 women having experienced unsafe abortion were identified by an empathetic approach and offered postabortion contraceptive service, which included counselling on HIV and condom use. Questionnaire interviews about contraceptive use were conducted at the time of inclusion and 12 months after the abortion. Additionally, in-depth interviews were performed 6–12 months after the abortion.

Results

Eighty-nine percent of the women accepted postabortion contraception. Follow-up information was obtained 12 months after the abortion among 59 percent of the women. Among these, 79 percent of the married women and 84 percent of the single women stated they were using contraception at 12 months. Condom use among the single women increased significantly during the 12 months follow up.

Conclusion

Postabortion contraceptive services appear to be well accepted by women who are admitted with complications after an unsafe abortion and should thus be recognized as an important means in addressing the problem of unsafe abortion. In addition, counselling about HIV and condom use should be considered an essential aspect of postabortion care.

Economic Status, Informal Exchange, and Sexual Risk in Kisumu, Kenya

Many observers believe that wealthy men play a disproportionate role in the continuing spread of HIV/AIDS infection in sub-Saharan Africa through their involvement in informal exchange relationships, where money and gifts (referred to as "transfers") are given to a range of nonmarital sexual partners. In this case, wealthier men are riskier sexual partners because they can afford to give larger transfers, which have been found to be negatively associated with condom use. Alternatively, wealthier men might have greater incentives to practice safe sex at later stages of the epidemic or wealthier men might match with female partners who have particularly strong preferences for condom use. Accordingly, economic status would be positively associated with condom use. We use survey data from urban Kisumu, Kenya, to investigate the various mechanisms through which economic status is associated with sexual risk behavior. Our results show that wealth is positively associated with transfers; wealth is uncorrelated with condom use, however. The characteristics of wealthier men's female partners also do not differ from the characteristics of poorer men's partners. We conclude that wealthier men have stronger preferences for condom use, which offsets the negative effect of larger transfers that they give to their sexual partners.

Whom can I rely on? Mothers’ approaches to support for feeding: An interview study in suburban Dar es Salaam, Tanzania

OBJECTIVE

to explore and describe mothers' perceptions of baby feeding and approaches to support for baby feeding.

DESIGN

individual qualitative semi-structured interviews conducted with mothers. Method used for analysis was qualitative content analysis.

SETTING

suburban Dar es Salaam, Tanzania.

PARTICIPANTS

8 mothers with babies under 6 months of age.

FINDINGS

the study revealed four categories of mothers' perceptions of baby feeding: (1) baby feeding, housework and paid work have to adjust to each other; (2) breast feeding has many benefits; (3) water or breast milk can be given to quench baby's thirst; and (4) crying provides guidance for baby feeding. Four different themes describing approaches to support emerged from the data: (1) adhering to diverse sources; (2) relying wholeheartedly on a mother figure; (3) working as a parental team; and (4) making arrangements for absence from the child.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

knowledge of the different approaches to support for baby feeding described in this study can help define counselling and promotional strategies in order to reach mothers with more effective messages and support for optimal baby-feeding practices.

Knowledge about safe motherhood and HIV/AIDS among school pupils in a rural area in Tanzania

Background

The majority of adolescents in Africa experience pregnancy, childbirth and enter motherhood without adequate information about maternal health issues. Information about these issues could help them reduce their pregnancy related health risks. Existing studies have concentrated on adolescents' knowledge of other areas of reproductive health, but little is known about their awareness and knowledge of safe motherhood issues. We sought to bridge this gap by assessing the knowledge of school pupils regarding safe motherhood in Mtwara Region, Tanzania.

Methods

We used qualitative and quantitative descriptive methods to assess school pupils' knowledge of safe motherhood and HIV/AIDS in pregnancy. An anonymous questionnaire was used to assess the knowledge of 135 pupils ranging in age from 9 to 17 years. The pupils were randomly selected from 3 primary schools. Underlying beliefs and attitudes were assessed through focus group interviews with 35 school children. Key informant interviews were conducted with six schoolteachers, two community leaders, and two health staffs.

Results

Knowledge about safe motherhood and other related aspects was generally low. While 67% of pupils could not mention the age at which a girl may be able to conceive, 80% reported it is safe for a girl to be married before she reaches 18 years. Strikingly, many school pupils believed that complications during pregnancy and childbirth are due to non-observance of traditions and taboos during pregnancy. Birth preparedness, important risk factors, danger signs, postpartum care and vertical transmission of HIV/AIDS and its prevention measures were almost unknown to the pupils.

Conclusion

Poor knowledge of safe motherhood issues among school pupils in rural Tanzania is related to lack of effective and coordinated interventions to address reproductive health and motherhood. For long-term and sustained impact, school children must be provided with appropriate safe motherhood information as early as possible through innovative school-based interventions.

Factors related to induced abortion among young women in Edo State, Nigeria

Sub-Saharan Africa has the highest death rate from induced abortion in the world, and young women in southern Nigeria are particularly likely to terminate their pregnancies. This study assesses the prevalence of and factors associated with induced abortion among 602 young women aged 15-24 who were surveyed in Edo State, Nigeria, in 2002. We find that 41 percent of all pregnancies reported by the young women surveyed were terminated, and we estimate the age-specific abortion rate for 15-19-year-olds in Edo State at 49 abortions per 1,000 women, which is slightly higher than previous local estimates and nearly double the countrywide estimate for women aged 15-49. We construct explanatory multivariate models to predict the likelihood that a young woman has experienced sexual intercourse, has become pregnant, and has undergone an induced abortion, controlling for important demographic and risk-behavior factors. Young women unmarried at the time of the interview are found to be significantly more likely than married women to have had an abortion. Young women who have experienced transactional or forced sex are also significantly more likely to report ever having had an abortion, as are young women who have experienced more than one pregnancy. We conclude with suggestions for modifying the content and target populations of behavioral change messages and programs in the area.

Acceptance and use of the female condom among women with incomplete abortion in rural Tanzania

BACKGROUND

This study describes the outcome of a postabortion care intervention aimed at introducing the female condom as a means of preventing women from having unwanted pregnancies and sexually transmitted infections (STIs)/HIV.

METHODS

Postabortion contraceptive counseling and services were offered to 548 women admitted to the Kagera Regional Hospital for incomplete abortion. The counseling included information about STI/HIV and the use male or female condom. In total, 521 (95%) women accepted contraception.

RESULTS

Contraceptive use was assessed 3 months after abortion among 475 (91%) women. The female condom was accepted by 201 of 521 (39%) and was used by 158 of 521 (30%). Women who had experienced an unsafe abortion, had attended secondary school or earned an income were more likely to accept the female condom. The women were generally satisfied with the method, and the majority intended to use it again.

CONCLUSION

Postabortion care programs provide an excellent entry point for introducing the female condom as a contraceptive method for the prevention of both repeat unwanted pregnancies and STI/HIV infection.

Factors that shape young people's sexual behaviour: a systematic review

BACKGROUND

Since nearly half of new HIV infections worldwide occur among young people aged 15-24 years, changing sexual behaviour in this group will be crucial in tackling the pandemic. Qualitative research is starting to reveal how social and cultural forces shape young people's sexual behaviour and can help explain why information campaigns and condom distribution programmes alone are often not enough to change it. We undertook a systematic review to identify key themes emerging from such research, to help inform policymakers developing sexual health programmes, and guide future research.

METHODS

We reviewed 268 qualitative studies of young people's sexual behaviour published between 1990 and 2004. We developed a method of comparative thematic analysis in which we coded each document according to themes they contained. We then identified relations between codes, grouping them accordingly into broader overall themes. Documents were classified as either primary or secondary depending on their quality and whether they contained empirical data. From the 5452 reports identified, we selected 246 journal articles and 22 books for analysis.

FINDINGS

Seven key themes emerged: young people assess potential sexual partners as "clean" or "unclean"; sexual partners have an important influence on behaviour in general; condoms are stigmatising and associated with lack of trust; gender stereotypes are crucial in determining social expectations and, in turn, behaviour; there are penalties and rewards for sex from society; reputations and social displays of sexual activity or inactivity are important; and social expectations hamper communication about sex. The themes do not seem to be exclusive to any particular country or cultural background, and all themes were present, in varying degrees, in all countries assessed.

INTERPRETATION

This study summarises key qualitative findings that help in understanding young people's sexual behaviour and why they might have unsafe sex; policymakers must take these into account when designing HIV programmes. Considerable overlap exists between current studies, which indicates the need to broaden the scope of future work.

Post-abortion care and voluntary HIV counselling and testing - an example of integrating HIV prevention into reproductive health services

OBJECTIVE

To assess the acceptance and outcome of voluntary HIV counselling and testing (VCT) among women who had an unsafe abortion.

METHOD

706 women were provided with post-abortion contraceptive service and offered VCT. We collected data on socioeconomic characteristics and contraceptive use and determined the HIV status of those who accepted VCT. Using a nested case-control design, we compared women who accepted HIV testing with women who did not. To study the association between socioeconomic factors, HIV testing acceptance and condom use in more detail, we did stratified analyses based on age and marital status.

RESULTS

58% of the women who had an unsafe abortion accepted HIV testing. Women who earned an income were more likely to accept testing than housewives. Women who accepted testing were more likely to accept using a condom. The HIV prevalence rate was 19% among single women aged 20-24 years and 25% among single women aged 25-45 years.

CONCLUSION

HIV testing and condoms were accepted by most women who had an unsafe abortion. The poor reproductive health of these women could be improved by good post-abortion care that includes contraceptive counselling, VCT and condom promotion.

Unsafe Abortion in Tanzania and the Need for Involving Men in Postabortion Contraceptive Counseling

Targeting male partners involved in unsafe abortions for contraceptive counseling could be an important strategy for decreasing the incidence of unwanted pregnancies, yet few postabortion-care programs have attempted to involve these men. To assess the need for and determine the content of postabortion contraceptive counseling for men, this study examined the contraceptive knowledge, attitudes, and practices of male partners of women who have had an unsafe abortion. A survey was administered to 213 men accompanying female partners receiving hospital care after having undergone an unsafe abortion in Dar es Salaam, Tanzania, and 20 of these men participated in in-depth interviews. Sixteen percent of the men surveyed accompanied an extramarital partner, and of those, only 44 percent reported having practiced contraception in the last six months, compared with 81 percent of the men accompanying their wives and 83 percent accompanying their girlfriends. In general, the men wished to support their partners in practicing contraception, and the majority were willing to participate in contraceptive counseling. These findings suggest that male partners should be included in postabortion contraceptive counseling, which should be sensitive to the nature of the partners' relationship, the risk of HIV transmission, and the importance of promoting gender

Scaling up postabortion contraceptive service — results from a study conducted among women having unwanted pregnancies in urban and rural Tanzania

INTRODUCTION

It is well recognized that unwanted pregnancies and unsafe abortion are significant public health problems in sub-Saharan Africa. At the International Conference on Population and Development held in Cairo in 1994, postabortion care was prioritized as a means to reduce maternal morbidity and mortality associated with unsafe abortion. However, only a few postabortion care programs have been implemented and most of them have been confined to urban settings. The present study describes the magnitude of the problem of unwanted pregnancies among women with incomplete abortion in urban and rural Tanzania and evaluates the outcome of a postabortion care intervention.

METHODS

Data were collected among 781 women admitted with incomplete abortion in Dar es Salaam region (urban Tanzania) and 575 women in Kagera region (rural Tanzania).

RESULTS

Sixty-seven percent of the women in urban Tanzania and 42% in rural Tanzania stated that their pregnancy was unwanted. Contraceptive acceptance among women with unwanted pregnancies was high; 93% in urban Tanzania and 71% in rural Tanzania left with a contraceptive method.

CONCLUSION

The high proportion of women with unwanted pregnancies in urban and rural Tanzania underlines the need of scaling up postabortion contraceptive service.

Acceptance of contraceptives among women who had an unsafe abortion in Dar es Salaam

OBJECTIVE

To assess the need for post-abortion contraception and to determine if women who had an unsafe abortion will use a contraceptive method to avoid repeated unwanted pregnancies and STDs/HIV.

METHOD

Women attending Temeke Municipal Hospital, Dar es Salaam, after an unsafe abortion or an induced abortion performed at the hospital (n=788) were counselled about contraception and the risk of contracting STDs/HIV. A free ward-based contraceptive service was offered and the women were asked to return for follow-up.

RESULTS

Participants (90%) accepted the post-abortion contraceptive service. Of these, 86% stated they were still using contraception 1-6 months after discharge. Initially, 55% of the women accepted to use condoms either alone or as part of double protection. After 1-6 months this proportion had dropped to 18%. Single women were significantly more likely to use condoms.

CONCLUSION

High-quality contraceptive service counselling can induce women to use contraception after having had an unsafe abortion. The results of our study are encouraging and should be used to convince policy makers of the need to implement such services at municipal level to reduce the number of repeated unsafe abortions.

A longitudinal study on different models of postabortion care in Tanzania

OBJECTIVE

To identify women having unsafe abortions and elucidate whether an acceptable follow-up rate among these women can be retrieved.

STUDY POPULATION

One thousand three hundred and fifty-seven women attended Temeke Municipal Hospital, Dar es Salaam with an abortion-related diagnosis.

METHODS

Women having unsafe abortions were identified by an empathetic dialogue, offered a contraceptive service and asked to return for follow-up. Three different ways of achieving follow-up information were tested. In phase 1, a combination of hospital-based and home-based interviews was utilized, in phase 2, an additional 1-month control visit was added to the protocol, and in phase 3, the contraceptive counseling and service was provided by technically well-skilled counselors.

RESULTS

Seven hundred and eighty-eight women were identified as having had unsafe abortions and 491 women as spontaneous abortions. Women having unsafe abortions were younger, more often single and of higher parity than women having spontaneous abortions. The follow-up rate achieved varied from 47%-72%, being lowest in phase 1 and highest in phase 3. The two most common reasons for loss to follow-up were the interviewer's inability to locate the respondent's house either because of an unspecific or a remote address (58%) and migration (29%).

CONCLUSION

If hospital-based and confidential home-based interviews are used combined and if the women having unsafe abortions are counseled by technically well-skilled counselors, it is possible to achieve a reasonable follow-up rate among women having unsafe abortions.

High rates of pregnancy among vocational school students: results of audio computer-assisted self-interview survey in Chiang Rai, Thailand

Unplanned pregnancy among young people can lead to adverse social, psychological, and health outcomes, particularly when it results in abortion. In 1999, we examined the prevalence of and factors associated with pregnancy and abortion among 1725 consenting vocational school students in northern Thailand. Results from an audio computer-assisted self-interview showed that 48% of the male and 43% of the female students reported ever having had sexual intercourse. Among those who had had intercourse, 27% of the women and 17% of the men said they or their partner had ever been pregnant. Among the last reported pregnancies that resulted in delivery or abortion, 95% were aborted. Age, current contraceptive use, early initiation of sexual intercourse (</=16 years), alcohol and drug use, and sexual coercion were associated with self or partner pregnancy. The high rates of pregnancy and abortion in this population indicate the need for better sexual health education and access to effective contraceptive methods.

Adolescent girls, illegal abortions and “sugar-daddies” in Dar es Salaam: vulnerable victims and active social agents

Adolescent girls' early sexual activity, early pregnancy, induced abortions and the increase in HIV infections have become major concerns in Sub-Saharan Africa. Efforts, though, to understand their sexual behaviour and to prevent reproductive health problems are almost non-existent. Adolescent girls are normally seen as victims and easy preys of (often older and married) men's sexual exploitation. This article, which is based on a qualitative study of 51 adolescent girls who had just had an illegal abortion in Dar es Salaam, Tanzania, reveals that these girls are not only victims but also willing preys and active social agents engaging in high-risk sexual behaviour. In order to get material benefits they expose themselves to serious health risks, including induced abortion - without realising their own vulnerability. In our study, one out of four girls had more than one partner at the time they became pregnant, and many counted on an illegally induced abortion if they got pregnant. Even if adolescents are now allowed free access to family planning information, education and services, our study shows that this remains in the realm of theory rather than practice. Moreover, most adolescent girls are not aware about their right to such services. The paper concludes that the vulnerability of adolescent girls increases without the recognition that sexuality education and contraceptive services do not constitute a licence to practice illicit sex - but rather a means to create more mature and responsible attitudes and to increase sexual and reproductive health.