High birth rates despite easy access to contraception and abortion: a cross-sectional study

Trends over 50 years with liberal abortion laws in the Nordic countries

BACKGROUND

During the 1970s the Nordic countries liberalized their abortion laws.

OBJECTIVE

We assessed epidemiological trends for induced abortion on all Nordic countries, considered legal similarities and diversities, effects of new medical innovations and changes in practical and legal provisions during the subsequent years.

METHODS

New legislation strengthened surveillance of induced abortion in all countries and mandated hospitals that performed abortions to report to national abortion registers. Published data from the Nordic abortion registers were considered and new comparative analyses done. The data cover complete national populations.

RESULTS AND CONCLUSIONS

After an increase in abortion rates during the first years following liberalization, the general abortion rates stabilized and even decreased in all Nordic countries, especially for women under 25 years. From the mid-1980s higher awareness about pregnancy termination led women to present at an earlier gestational age, which was accelerated by the introduction of medical abortion some years later. Most terminations (80-86%) are now done before the 9th gestational week in all countries, primarily by medical rather than surgical means. Introduction of routine ultrasound screening in pregnancy during the late 1980s, increased the number of 2nd trimester abortions on fetal anomaly indications without an overall increase in the proportion of 2nd relative to 1st trimester abortions. Further refinement of ultrasound screening and non-invasive prenatal diagnostic methods led to a slight increase in the proportion of early 2nd trimester abortions after the year 2000. Country-specific differences in abortion rates have remained stable over the 50 years of liberalized abortion laws.

Immigrant women’s perspectives on contraceptive counselling provided by midwives in Sweden – a qualitative study

Immigrant women in Sweden often have unmet sexual and reproductive health (SRH) needs. Successful contraceptive counselling may improve their sexual and reproductive health and rights. The unique Swedish model, with midwives as the main providers of contraceptive counselling, is important for immigrant women’s health at both individual and societal levels. This study explored immigrant women’s perspectives on receiving contraceptive counselling from midwives in Sweden, in order to obtain deeper knowledge about the factors they perceive as important in the counselling situation. Nineteen in-depth individual interviews were conducted from December 2018 to February 2019, followed by qualitative manifest and latent content analysis. Trust emerged as the overall important factor in the contraceptive counselling meeting. Knowledge was lacking about the midwife’s professional role as a contraceptive counsellor. Contraceptive counselling was seen as a private matter not easily shared with unfamiliar midwives or interpreters. Previous experiences of contraceptives and preconceptions were important considerations for contraceptive choice, but communicating these needs required trust. Women also wanted more knowledge about contraceptives and SRH care and rights. Cultural and social norms concerning when and why to use contraceptives needed to be acknowledged in the midwife encounter. Although immigrant women want more knowledge about contraception, a trustful relationship with the midwife is needed to be able to make informed contraceptive choices. Midwives may need increased awareness of the many factors influencing immigrant women's choices to ensure their contraceptive autonomy. Policy changes that promote new ways of counselling and ability to provide continuous care are needed.

Attitudes Toward the Copper IUD in Sweden: A Survey Study

Background

While the efficacy and safety of the contraceptive copper intrauterine device (IUD) have been affirmed, alongside its importance for the prevention of unintended pregnancies, some studies have pointed to negative attitudes toward the device. In recent years, social media communication about it has included claims about systemic side effects, unsubstantiated by medical authorities. Research from the Swedish context is sparse. This study investigates attitudes toward the copper IUD and any correlations between negative attitudes toward or experiences of the device, and (1) sociodemographic characteristics, (2) the evaluation of the reliability of different sources of information, and (3) trust in healthcare and other societal institutions.

Methods

A survey was distributed online to adult women in Sweden (n = 2,000). Aside from descriptive statistics, associations between negative attitudes toward or experiences of the copper IUD and sociodemographic and other variables were calculated using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). Open survey responses (n = 650) were analyzed thematically.

Results

While many reported positive attitudes toward and experiences of the IUD, 34.7% of all respondents reported negative attitudes and 45.4% of users reported negative experiences. Negative attitudes were strongly correlated with negative experiences. Negative attitudes and experiences were associated with low income, but no conclusive associations were identified with other socioeconomic variables. Negative attitudes and experiences were associated with lower levels of confidence in and satisfaction with healthcare, as well as lower self-assessed access and ability to assess the origin and reliability of information about the IUD. In open responses, negative comments were prevalent and included references to both common and unestablished perceived side-effects. Respondents pointed to problematic aspects of information and knowledge about the copper IUD and called for improved healthcare communication and updated research.

Conclusion

Healthcare provider communication about the copper IUD should promote reproductive autonomy and trust by providing clear information about potential side effects and being open to discuss women's experiences and concerns. Further research on copper IUD dissatisfaction and ways in which health professionals do and may best respond to it is needed.

Environmental factors in declining human fertility

A severe decline in child births has occurred over the past half century, which will lead to considerable population declines, particularly in industrialized regions. A crucial question is whether this decline can be explained by economic and behavioural factors alone, as suggested by demographic reports, or to what degree biological factors are also involved. Here, we discuss data suggesting that human reproductive health is deteriorating in industrialized regions. Widespread infertility and the need for assisted reproduction due to poor semen quality and/or oocyte failure are now major health issues. Other indicators of declining reproductive health include a worldwide increasing incidence in testicular cancer among young men and alterations in twinning frequency. There is also evidence of a parallel decline in rates of legal abortions, revealing a deterioration in total conception rates. Subtle alterations in fertility rates were already visible around 1900, and most industrialized regions now have rates below levels required to sustain their populations. We hypothesize that these reproductive health problems are partially linked to increasing human exposures to chemicals originating directly or indirectly from fossil fuels. If the current infertility epidemic is indeed linked to such exposures, decisive regulatory action underpinned by unconventional, interdisciplinary research collaborations will be needed to reverse the trends.

Reproductive changes among women in their 40s: A cross-sectional study

INTRODUCTION

The aim was to describe and compare changes in the reproductive pattern of women in their 40s observed over a decade in Scandinavia.

MATERIAL AND METHODS

Cross-sectional study using the total population of women aged 40-49 years between 2008-2018 in Denmark, Norway and Sweden (on average n = 1.5 million). Aggregated data concerning birth and induced abortion rate were collected and analyzed from national health registers. National data on redeemed prescriptions of hormonal contraceptives in the three countries were collected from prescription registers. Births after spontaneous and assisted conceptions were identified by using cross-linked data on deliveries from the Medical Birth Registers and National Registers of Assisted Reproduction in the three countries.

RESULTS

Use of hormonal contraception increased among women aged 40-44 years in Denmark from 24% to 31%, in Sweden from 27% to 30%, and in Norway from 22% to 24%. The levonorgestrel-releasing intrauterine device was the most frequently used method in all countries. Birth rates among women 40-44 years increased continuously from 9.5 to 12/1000 women in Denmark and from 11.7 to 14.3/1000 in Sweden, but remained stable in Norway at ~11/1000 women. There was a doubling of assisted conceptions in Denmark from 0.71 to 1.71/1000 women, Sweden from 0.43 to 0.81/1000 and Norway from 0.25 to 0.53/1000 women 40-49 years of age. Sweden had the highest induced abortion rate (7.7 to 8.1/1000 women) in women aged 40-49 years during the study period.

CONCLUSIONS

From 2008 to 2018, birth rates continuously increased among women aged 40-49 years in Denmark and Sweden and births resulting from assisted reproductive technology doubled in all three countries.

Trends in the use of hormonal contraception in Estonia 2005-2019 and the risk of arterial and venous thromboembolism: a population-based study

PURPOSE

To describe trends in hormonal contraceptive use, incidence of thromboembolism and presence of risk factors for thromboembolism among the users in Estonia.

MATERIAL AND METHODS

Data of 223 312 female patients aged 15-49 years in 2005-2019 from national health insurance databases was derived. Annual prevalence rates of hormonal contraceptive users, incidence rates of thromboembolism and prevalence rates of risk factors were calculated.

RESULTS

Between 2005-2019 usage of progestogen-only contraceptives (POCs) increased steadily (from 24 to 135 users per 1000 population), whereas combined hormonal contraceptive (CHC) use declined (from 209 in 2012 to 161 users per 1000 population in 2019). During the study period, 390 cases of venous thromboembolism and 108 arterial thromboembolism coincided with hormonal contraceptive use. Incidence rate for venous thromboembolism was 5.0 (95% CI 4.5-5.5) and for arterial thromboembolism 1.4 per 10 000 person-years (95% CI 1.1-1.7) among hormonal contraceptive users. Age adjusted incidence of venous thromboembolism among CHC users was 5.8 (95% CI 4.1-8.2) times higher than in POC users. Among CHC users, 10.3% had more than one risk factor for thrombosis.

CONCLUSIONS

In regards to the risk of thromboembolism, wider use of POCs and declining prevalence of CHCs in Estonia is positive trend. Still, women with history of thrombosis receiving CHC is a serious concern.

Population-level indicators associated with hormonal contraception use: a register-based matched case-control study

Background

Monitoring factors related to hormonal contraception (HC) use is essential to evaluating public health strategies and promoting access to contraception. We aimed to examine municipal social and health indicators of HC use at the population level, and to identify patterns of inequality across Finnish municipalities.

Methods

We identified all women (15–49 years) with a redeemed HC prescription in Finland in 2017 (n = 294,445), and a control group of non-users. Municipal social and health indicators at the population level were retrieved from the nationwide Statistics and Indicator Bank. Differences between the groups across 309 municipalities were calculated, and associations of municipal-specific proportions of HC users with municipal-specific indicators were studied using LASSO (Least Absolute Shrinkage and Selection Operator) models.

Results

Sociodemographic differences between HC users and non-users were non-homogenous across municipalities. Indicators positively associated with HC use included: larger population and higher proportions of population aged 16–24 years, of household-dwelling units with one person, of persons with higher education, and of divorces among those aged 25–64. Lower HC use was associated with higher proportions of Swedish-speaking population, of those aged 7–15 years, of young people not in education/training, and of household-dwelling units in overcrowded conditions. Lower HC use was also associated with indicators of outpatient and inpatient healthcare, and of municipal finances in welfare and healthcare.

Conclusions

Sociodemographic differences in relation to HC use exist across Finnish municipalities. Municipal indicators of social structure, health and welfare, and investment in and use of healthcare services are related to HC use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10512-6.

"I have turned into a foreman here at home." Families and work-life balance in times of Covid-19 in a gender equality paradise

This article explores the gendered realities of work–life balance in Iceland during the COVID‐19 pandemic, in particular how these societal changes reflect and affect the gendered division of unpaid labor, such as childcare and household chores. The study draws on open‐ended real‐time diary entries, collected for 2 weeks during the peak of the pandemic in Iceland. The entries represent the voices of 37 mothers in heteronormative relationships. The findings imply that, during the pandemic, the mothers took on greater mental work than before. They also described intense emotional labor, as they tried to keep everyone calm and safe. The division of tasks at home lay on their shoulders, causing them stress and frustration. The findings suggest that, even in a country that has been at the top of the Gender Gap Index for several years, an unprecedented situation like COVID‐19 can reveal and exaggerate strong gender norms and expectations toward mothers.

Evidence on factors influencing contraceptive use and sexual behavior among women in South Africa: A scoping review

INTRODUCTION

Contraceptive use and sexual health behavior remain a prominent public health concern in South Africa (SA). Despite many government interventions, unintended pregnancies and termination of pregnancies remain relatively high. This review aimed to map evidence on factors influencing contraceptive use and sexual behavior in SA.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's framework. We searched for articles from the following databases: PubMed/MEDLINE, American Doctoral Dissertations via EBSCO host, Union Catalogue of Theses and Dissertations (UCTD) and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. Studies published from January 1990 to March 2018 were included. We used the Population, Concept, and Context (PCC) framework and the PRISMA chart to report the screening of results. The Mixed Method Appraisal Tool (MMAT) version 11 and ACCODS tools were used to determine the quality of the included studies.

RESULTS

A total of 2030 articles were identified by our search criteria for title screening. Only 21 studies met our inclusion criteria and were included in quality assessment stage. We found that knowledge of a contraceptive method, length of a relationship, sexual debut, age difference between partners availability of a contraceptive method, long waiting hours, and nurse's attitudes toward human immunodeficiency virus (HIV) positive or younger clients predict whether or not women use a contraceptive method or improve sexual behavior.

CONCLUSION

There remains a necessity for improving educational programs aimed at transferring knowledge on contraceptives and sexual behavior to both women and their male counterparts, alongside the public health systems' improvements.

Short interpregnancy interval and poor fetal growth: Evaluating the role of pregnancy intention

BACKGROUND

Previous studies have demonstrated that short interpregnancy interval (the interval between delivery and estimated last menstrual period of a subsequent pregnancy) is associated with small for gestational age birth. It is controversial if this association is causal, as few studies have accounted for likely confounding factors such as unintended pregnancy. We examined the association between interpregnancy interval and infant birthweight, adjusting for pregnancy intention and other socio-economic and obstetrical risk factors.

METHODS

We used data from the Scandinavian Successive Small-for-Gestational-Age births study (1986-1988). Birthweight was expressed as a gestational age-standardised z-score.

RESULTS

Among 1406 women, a trend towards lower birthweight z-score with short interpregnancy interval was not statistically significant (unadjusted difference in birthweight z-score of -0.25, 95% confidence interval (CI) -0.55, 0.05). After adjusting for pregnancy intention, detailed measures of socio-economic status, and other covariates, the estimated magnitude of effect between interpregnancy interval and birthweight z-score was further attenuated (adjusted difference in birthweight z-score of -0.13, 95% CI -0.46, 0.20).

CONCLUSIONS

In this cohort study with detailed information on pregnancy intention and socio-economic status, short interpregnancy interval was not associated with lower birthweight. These findings suggest that previously observed associations between short interpregnancy interval and lower birthweight may reflect confounding by socio-economic and/or other unmeasured confounders.

Contraceptive use and reproductive intentions among women requesting contraceptive counseling

Introduction

Limited attention has been paid to the use of contraception in relation to women's family planning intentions. The aim of this study was to investigate the use of contraception during the most recent intercourse as well as the reproductive intentions of Swedish‐speaking women requesting contraceptive counseling.

MATERIAL AND METHODS

A cross‐sectional baseline survey in a randomized controlled trial regarding reproductive life planning (before randomization). Women requesting contraceptive counseling answered questions about contraception and whether they wanted to have children/more children in the future.

Results

In total, 1946 women participated: 33.7% (n = 656) parous and 65.7% (n = 1279) nulliparous. The majority, 87.1% (n = 1682), had used contraception during their latest intercourse; 64.6% (n = 1239) used short‐acting reversible contraception, 22.8% (n = 443) used long‐acting reversible contraception (LARC), and 12.9% (n = 251) had not used any contraception. A combined oral contraceptive was more common among nulliparous and LARC among parous. Among all women, 64.8% (n = 1253) intended to have children/more children in the future, among parous women 35.7% (n = 220) and among nulliparous 80.0% (n = 1033). Among women who did not intend to have children/more children, 22.6% (n = 60) of parous and 10% (n = 8) of nulliparous had not used contraceptives during their most recent intercourse.

Conclusions

Women did not always use contraceptives that were suitable for their reproductive intentions. Questioning women who request contraceptive counseling about their pregnancy intention can give healthcare providers better opportunities for individualized counseling.