Barriers to effective contraception and strategies for overcoming them among adolescent mothers

Developmental pathways from child maltreatment to adolescent pregnancy: A multiple mediational model

Adolescent pregnancy (AP) is a significant public health issue. Child maltreatment (CM) represents an established risk factor, yet little is known about the explanatory mechanisms linking the phenomena. Informed by developmental theory, this study prospectively tested seven multi-level, indirect pathways that could plausibly explain the relationship between CM and AP: (1) substance use (polysubstance use and frequency); (2) sexual risk behavior; (3) depressive symptoms; (4) posttraumatic stress disorder symptoms; (5) cognitive dysregulation; (6) pregnancy desire and difficulty expectancies; and (7) age at menarche. Data came from a prospective, longitudinal cohort study of 469 ethnically diverse, nulliparous adolescent females, designed to examine the impact of substantiated CM on reproductive outcomes such as pregnancy and childbirth (265 maltreated and 204 demographically matched comparison adolescents). A multiple-mediator structural equation model was conducted to simultaneously test multiple indirect effects while accounting for confounding variables. Maltreatment had an indirect effect on pregnancy via substance use and higher pregnancy desire/lower perceived difficulty. Findings represent a step towards elucidating pathways linking CM with AP. Recommendations are offered to prevent pregnancy by addressing the pregnancy-specific mechanisms that are part of the maltreatment sequelae.

Family Planning Attitudes, Religious Orientation and Fatalistic Tendency Levels: A Descriptive-Correlational Study in Turkey

This research was conducted to examine the relationship between family planning attitudes, religious orientation, and fatalistic tendency levels of individuals aged 15-49 in Igdir, Turkey. This descriptive-correlational research was conducted on individuals living in Igdir between March-July 2020. The sample size of our study is 384 participants. It was found that there was a significant negative correlation between family planning attitude scale scores and religious orientation scale behavior subscale scores, fatalistic tendency scale total scores and all subscale scores, age, and number of children (p < 0.05). It was found that there was a significant negative correlation between religious orientation scale total scores and the attitude toward family planning and attitude toward birth subscale scores of the family planning attitude scale (p < 0.05). A significant positive correlation was found between religious orientation scale total scores and all subscale scores, fatalistic tendency scale total scores, and predetermination and self-control subscales (p < 0.05). There was also a significant negative correlation between fatalistic tendency scale total scores and family planning attitude scale total scores and the attitude toward family planning and attitude toward family planning methods subscale scores (p < 0.05). We also found a significant positive correlation between fatalistic tendency scale total scores and all subscale scores, religious orientation scale total scores and all subscale scores, age, and number of children (p < 0.05). It is recommended to apply the study in larger groups.

Medical conditions, pregnancy perspectives and contraceptive decision-making among young people: an exploratory, qualitative analysis

OBJECTIVE

To explore perspectives on family planning among young people who perceive they are infertile or will have difficulty carrying a pregnancy to term owing to medical conditions or procedures.

METHODS

This exploratory analysis examined pregnancy plans and contraceptive behavior among 12 young adults with a diagnosed medical condition or who had undergone a medical procedure associated with impaired fertility, and who had discussed fertility with a healthcare provider. We utilized data from a larger study investigating prospective pregnancy intentions and plans among 50 young (ages 18-24) women and their male partners (n=100).

RESULTS

Medical conditions included endometriosis, polycystic ovary syndrome, and lupus. For some, medical conditions/procedures led to use of no or less effective contraception; perceived risk for pregnancy was low, though seven participants had previously experienced pregnancies. Participants also described how medical conditions altered their timelines for pregnancy and overall desire for children; for example, one participant described continuing an unplanned pregnancy because she feared it would be her only chance to parent.

CONCLUSION

This exploratory analysis suggests that among young people, medical issues perceived to affect fertility and pregnancy may influence pregnancy planning and contraceptive behavior. Young people may lack knowledge about fertility and the impact of a medical condition; thus it is critical that providers clarify the difference between anticipated difficulty conceiving and complete infertility. Tailored contraceptive care is needed for young adults with medical conditions that may affect fertility to ensure they have the necessary information to make informed family planning decisions.

IMPLICATIONS

Medical conditions known to affect fertility may influence young people's family planning desires and behaviors. Understanding how young adults process information about medical conditions' impact on their fertility and change or make plans in response is important in order to best meet their family planning needs.

The Complexity of Multiple Contraceptive Method Use and the Anxiety That Informs It: Implications for Theory and Practice

Despite clinical guidelines and national data describing the use of one contraceptive method as the best and most common way to prevent unintended pregnancy, limited evidence indicates a more complex picture of actual contraceptive practice. Face-to-face in-depth interviews were conducted in November of 2013 with a sample of women from two cities in the United States (n = 52). The interviews explored the ways participants used contraception to protect themselves from unintended pregnancy over the past 12 months. Most respondents reported using multiple methods, many of which are considered to be less-effective, within this timeframe. The practice of combining methods in order to increase one's level of protection from pregnancy was prevalent, and was mainly enacted in two ways: by backing up inconsistent method use with other methods and by "buttressing" methods. These practices were found to be more common, and more complex, than previously described in the literature. These behaviors were mainly informed by a deep anxiety about both the efficacy of contraceptive methods, and about respondents' own perceived ability to prevent pregnancy. These findings challenge prevailing assumptions about women's contraceptive method use and have implications for clinical contraceptive counseling practice.

What do Women Want? Experiences of Low-Income Women with Postpartum Contraception and Contraceptive Counseling

BACKGROUND

Contraceptive counseling can increase postpartum contraception use, yet the optimal method and timing for counseling are unknown. The objective was to investigate preferences of underserved pregnant and postpartum women regarding contraception use and counseling.

METHOD

Surveys regarding contraception experiences and perceptions of contraceptive counseling were conducted with 57 women age 18 and older who were postpartum or antepartum with a previous delivery within 5 years and receiving Medicaid-funded care at an academic medical center. Health literacy was assessed using REALM-7. Responses were analyzed using descriptive statistics.

RESULTS

A majority of women reported unplanned pregnancies (78%). Women using contraception at the time of conception reported "not sure" (30%) and "taken wrong" (30%) as primary reasons for failure. Most subjects had at least a high school level of health literacy (88%), desired to use a postpartum contraceptive method (92%) and had a high self-reported understanding of that method (94%). Most women reported receiving counseling (91%) and stated that the best time for counseling was both before and after childbirth (84%). However, only 60% of subjects intended to use the method they were prescribed at discharge; reasons for changing included side effects (37%), desire for different contraception (23%) and too complicated of a method prescribed (17%).

CONCLUSION

Women perceived the best timing of contraceptive education to be both antepartum and postpartum. Despite a high frequency of prior contraceptive failure, self-reported understanding of the chosen postpartum contraceptive method was high. Contraception counseling should be tailored to a woman's perceived needs, with such education occurring frequently and within the context of her health literacy.

Importance of social support in preventing alcohol-exposed pregnancies with American Indian communities

Recent research concludes that prevention of alcohol-exposed pregnancies (AEP) must occur with preconceptional women, either by reducing alcohol consumption in women at-risk or planning pregnancy or preventing pregnancy in women drinking at risky levels. One AEP prevention program currently underway with non-pregnant American Indian women is the Oglala Sioux Tribe (OST) Changing High-risk alcohOl use and Increasing Contraception Effectiveness Study (CHOICES) Program. The OST CHOICES Program shows promise in lowering the AEP risk in American Indian women, and it is a natural next step to evaluate the potential impact that social support can have on further encouraging behavioral changes. Focus groups with community members and key informant interviews with health and social service professionals were completed. To uncover and interpret interrelated themes, a conventional content analysis methodology was used. Eight focus groups were held with 58 American Indian participants, including adult women of child-bearing age, elder women, and adult men. Key informant interviews were completed with 25 health and social service professionals. Based on input from the focus groups and key informant interviews, several subthemes regarding social support in the prevention of AEP stood out, including the role of family (especially elders), the impact community can have, and the important function of culture. In this study, we highlighted the important influence that social support can have on AEP prevention, especially among the American Indian population, where social support has cultural and historical significance.

Understanding the effects of MTV's 16 and Pregnant on adolescent girls' beliefs, attitudes, and behavioral intentions toward teen pregnancy

This article examines the impact of a popular documentary series about teen pregnancy, MTV's 16 and Pregnant, on adolescent girls' pregnancy-related attitudes, beliefs, and behavioral intentions. The results suggest that girls who watched 16 and Pregnant, compared with a control group, reported a lower perception of their own risk for pregnancy and a greater perception that the benefits of teen pregnancy outweigh the risks. The authors also examined the relationships between homophily and parasocial interaction with the teen moms featured in 16 and Pregnant and attitudes, beliefs, and behavioral intentions, finding that homophily predicted lower risk perceptions, greater acceptance of myths about teen pregnancy, and more favorable attitudes about teen pregnancy. Parasocial interaction demonstrated the same pattern of results, with the addition of also predicting fewer behavioral intentions to avoid teen pregnancy. Last, results revealed that teen girls' perceptions that the message of 16 and Pregnant was encouraging of teen pregnancy predicted homophily and parasocial interaction with the teen moms. Theoretical and practical implications are discussed.

Life experiences of instability and sexual risk behaviors among high-risk adolescent females

CONTEXT

Understanding the interplay of multiple contexts of adolescents' sexual risk behaviors is essential to helping them avoid pregnancy and STDs. Although a body of research has identified multiple individual- and family-level variables associated with adolescents' sexual risk behaviors, relatively few studies have examined relationships between these behaviors and latent indicators of unstable, chaotic environments.

METHODS

In 2007-2008, a sample of 241 sexually active adolescent females who were at high risk for pregnancy and STDs were recruited through two school-based clinics and two community clinics in Minneapolis and St. Paul. Confirmatory factor analysis was used with baseline data to specify latent constructs of individual risk and family disengagement. Structural equation models examined longitudinal relationships between baseline measures of these constructs and sexual risk behaviors assessed six months later.

RESULTS

The latent construct of individual risk encompassed substance use, violence perpetration, violence victimization and having witnessed violence; that of family disengagement included family disconnection, poor family communication and perceived lack of safety at home. Baseline level of individual risk was positively associated with number of male sex partners six months later (path coefficient, 0.2); it was not associated with consistent condom use at follow-up. Level of family disengagement was negatively associated with condom use consistency six months later (-0.3), but was not associated with number of male sex partners.

CONCLUSIONS

To meet the health needs of vulnerable adolescents, health systems should incorporate coordinated and interdisciplinary services that acknowledge adolescents' relevant familial and social contexts.

Missed conceptions or misconceptions: perceived infertility among unmarried young adults in the United States

CONTEXT

Perceived infertility is an individual's belief that she or he is unable to conceive or impregnate, regardless of whether this belief is medically accurate. This perception may lead to contraceptive nonuse, which may, in turn, lead to unintended pregnancy. Little research has examined perceived infertility among young adults, including potential associations with contraceptive behaviors.

METHODS

The frequency of perceived infertility among young adults was assessed using 2009 data from a nationally representative telephone survey of 1,800 unmarried men and women aged 18-29. Multinomial regression analyses assessed associations between respondents' perceived infertility and selected background, reproductive knowledge, sexual experience and contraceptive use characteristics.

RESULTS

Overall, 19% of women and 13% of men believed that they were very likely to be infertile. Hispanic women and women who had received public assistance in the past year had elevated odds of perceived infertility (odds ratios, 3.4 and 3.0, respectively), as did Hispanic men and men of other racial or ethnic minorities, except blacks (2.5 and 6.1, respectively). Men who had some college education, had received sex education or were not in a current relationship had decreased odds of thinking they were very likely to be infertile (0.3-0.4). Among men, perceived infertility was associated with the belief that they were likely to have sex without using a contraceptive in the next three months (2.6).

CONCLUSIONS

A substantial proportion of young adults believe they are infertile. Improved provider counseling and sex education may be useful in helping them to better understand their actual probability of infertility, and this knowledge may lead to improved contraceptive use.

Hispanic Familism Reconsidered: Ethnic Differences in the Perceived Value of Children and Fertility Intentions

Familism has been described as a cultural trait that might explain why the fertility of Hispanic women remains higher than non-Hispanic White women. Still, few studies have analyzed group differences in childbearing attitudes. This paper focuses on two dimensions of childbearing orientation: social value of children and fertility intentions. Using the National Survey of Family Growth we find limited support for the idea that familism undergirds differentials in fertility between native-born Hispanics and Whites. However, for foreign-born Hispanics, there are some differences in the perceived value of children compared with Whites, and these differences could contribute to fertility differentials.

Social network effects in contraceptive behavior among adolescents

OBJECTIVE

To quantify empirically the role of peer social networks in contraceptive behavior among adolescents.

METHOD

Using longitudinal data from a nationally representative sample of adolescents, the authors use a multivariate structural model with school-level fixed effects to account for the problems of contextual effects, correlated effects, and peer selection to reduce the potential impact of biases from the estimates of peer influence. The peer group measures are drawn not only from the nominations of close friends but also from classmates. Contraception use among the peer groups was constructed using the peers' own reports of their contraceptive behavior.

RESULTS

Controlling for parental characteristics and other demographic variables, the authors find that a 10% increase in the proportion of classmates who use contraception increases the likelihood of individual contraception use by approximately 5%. They also find evidence that the influence of close friends diminishes after accounting for unobserved environmental confounders.

CONCLUSION

The findings of this study support the findings in the literature that peer effects are important determinants of contraception use even after controlling for potential biases in the data. Effective policy aimed at increasing contraception use among adolescents should consider these peer effects.

The role of the social network in contraceptive decision-making among young, African American and Latina women

PURPOSE

Understanding reasons for contraception decisions is critical to improving our ability to reduce rates of unintended pregnancies. We used an in-depth qualitative approach to examine the contraceptive decision-making process, with special attention to the role of the social network, among a group of young, postpartum urban minority women.

METHODS

Brief surveys and semi-structured interviews were conducted with 30 consenting postpartum women. In-person one-on-one interviews were then reviewed for themes using an iterative process. Qualitative analysis techniques identifying emergent themes were applied to interview data.

RESULTS

In this cohort of African American (63%) and Hispanic (37%) women (median age, 26), 73% had unplanned pregnancies. The social network, including friends, mothers, and partners, were key sources of contraception myths, misconceptions, and vicarious experiences. Women also utilized media, including the internet, as an additional source of information. Information relayed by the social network had a direct influence on contraceptive decisions for many women.

CONCLUSIONS

The experiences and opinions of the social network influence contraceptive decisions in this population of young, minority women. The social network, including friends, family members, and media sources, is a key source of contraceptive information for many women. Comprehensive contraception counseling should explore the experiences and opinions of the patient's social network to the extent possible.

Birth outcomes and risk factors in adolescent pregnancies: results of a Taiwanese national survey

BACKGROUND

This study explores birth outcomes and determinants in adolescent pregnancies, using subjects drawn from the Taiwan Birth Cohort Study (TBCS) from 2005.

METHODS

Through completed interviews and surveys with mothers or other family members, differences in birth outcomes and personal, pregnancy and social profiles of mothers were analyzed.

RESULTS

A total of 533 adolescent mothers (<20 years old) and 9347 adult mothers (20-34 years old) were included in our study. There was a significantly higher incidence of low birthweight (LBW) (<2500 g, 10.2% vs 5.6%) and premature birth (<37 weeks, 14.8% vs 8.6%) in the adolescent group. When adjusted for covariates in the multiple-variable model, youth remained a risk factor for LBW (OR = 1.50, 95%CI 1.09, 2.07) and premature delivery (OR = 1.42, 95%CI 1.07, 1.89). Age, prenatal care and weight gain during pregnancy are important predictors of LBW and premature birth.

CONCLUSION

Adolescent pregnancy carries a high-risk of LBW and premature birth. Inadequate prenatal care and weight gain during pregnancy are contributing factors that could be improved through strategies of health education, family support and case management.

Multilevel predictors of inconsistent condom use among adolescent mothers

OBJECTIVES

We used Bronfenbrenner's ecological systems theory to identify factors that predicted never or sometimes using condoms in a multiethnic cohort of adolescent mothers.

METHODS

We interviewed adolescent mothers within 48 hours of delivery and surveyed them 6 and 12 months after delivery (n = 636). We used multinomial logistic regression to identify individual-, dyad-, family-, and peer and community-level factors associated with never or sometimes using versus always using condoms during intercourse at 12 months postpartum.

RESULTS

Pregnancy status, partner refusal to use condoms, intimate partner violence, and race/ethnicity predicted both never and sometimes using condoms. Condom use 6 months earlier and church attendance also predicted never using condoms, whereas maternal monitoring was an additional predictor for sometimes using condoms.

CONCLUSIONS

Overlapping yet distinct risk profiles predicted never or sometimes using versus always using condoms. Factors from multiple levels of influence affected the condom use behaviors of adolescent mothers indicating that multilevel interventions are needed to promote safer sexual practices among these young women.

The influence of nurse home visits, including provision of 3 months of contraceptives and contraceptive counseling, on perceived barriers to contraceptive use and contraceptive use self-efficacy

OBJECTIVE

To identify the influence of a community health nurse (CHN) home visit on perceived barriers to contraceptive access and contraceptive use self-efficacy.

METHODS

We enrolled 103 women into two groups in a randomized trial evaluating the influence of contraceptive dispensing and family planning counseling during home visits on perceived barriers to accessing contraceptives and contraceptive use self-efficacy. Both groups received counseling by a CHN about sexually transmitted disease and pregnancy prevention, and a resource card listing phone numbers of family planning clinics. After randomization, the CHN dispensed three months of hormonal contraception to the intensive intervention group and advised the minimal intervention group to schedule an appointment at a family planning clinic. Data collection at baseline and 12 months included demographic, reproductive and other health-related information as well as quantitative assessments of information on perceived barriers to contraceptive access and contraceptive use self-efficacy.

RESULTS

The mean age of participants was 24.7 years. Three-fourths had household incomes under $25,000. We found significant reductions in three perceived barriers to contraceptive access for both groups, as well as significant increases in two measures of contraceptive use self-efficacy at twelve months compared to baseline.

CONCLUSION

Nurse home visits involving family planning counseling might be effective in reducing perceived barriers to contraceptive access and increasing contraceptive use self-efficacy.

Adolescent pregnancy diagnosis and outcomes: a six-year clinical sample

STUDY OBJECTIVE

To explore pregnancy diagnosis, outcome choice, and time to referral appointment for adolescents.

DESIGN

A descriptive study using retrospective chart review and clinical logs of all positive pregnancy tests between January 2000 and December 2005.

SETTING

Adolescent clinic in a hospital-based academic center.

PARTICIPANTS

625 pregnant teens were identified. Thirteen teens (2%) were lost to follow-up. Exclusion criteria included teens with advanced pregnancy, 22 weeks gestation or older at initial pregnancy diagnosis (n=11).

INTERVENTIONS

All pregnant teens participated in a multidisciplinary tracking program.

MAIN OUTCOME MEASURES

Outcome choice and time interval to prenatal or termination appointment.

RESULTS

The 601 pregnant teens had a mean age of 18.2 years with a range of 13 to 23 years. Pregnancy outcomes indicate 48.2% (N=290) opted to continue their pregnancy and entered prenatal care, 45% (N=275) chose to terminate, and 6% (N=36) experienced a miscarriage. Adolescents who continued their pregnancy presented with a mean gestational age of 7.98 weeks versus 7.20 weeks for teens choosing to terminate (P < or = 0.001). They also had a significantly longer time interval to their referral site, averaging 24 days until a prenatal appointment, compared to 17 days for a termination (P < or = 0.05).

CONCLUSION

Over the six-year study period, the number of adolescent pregnancies diagnosed within this clinical site remained constant. Adolescents who chose to continue their pregnancy were more likely to present later for diagnosis and experienced a longer wait time to their referral appointment for prenatal care. Pregnant adolescents may delay entry into timely reproductive health services.

Testing a model of contraception use behavior among sexually active female adolescents in Taiwan

The purpose of this cross-sectional study was to test a model of contraception use among sexually active Taiwanese female adolescents, using structural equation modeling. Anonymous questionnaires were distributed to 404 female adolescents who had had sexual intercourse in the previous 3 months. A model was produced in which past contraception use, self-efficacy for contraception use, and decisional balance for using contraception had significant direct effects on current contraception use. Social influences had not only significant direct effects on self-efficacy and on decisional balance, but also a significant indirect effect on current contraception use. These findings provide a reference for the development of contraceptive intervention programs for sexually active female adolescents in Taiwan.

Contraception use and pregnancy among 15-24 year old South African women: a nationally representative cross-sectional survey

BACKGROUND

Adolescent reproductive health has not continued to receive the attention it deserves since the start of the HIV epidemic. In South Africa, high numbers of adolescent women report pregnancies that are unwanted and yet few have accessed available termination of pregnancy services. Enabling contraception use is vital for meeting the goals of HIV prevention.

METHODS

A nationally representative survey of South African 15-24 year olds was undertaken. Participants completed a questionnaire on sexual behaviour and provided an oral fluid sample for HIV testing. Analysis of the data was restricted to women (n = 6217), particularly those who reported being sexual active in the last 12 months (n = 3618) and was conducted using svy methods in the program STATA 8.0 to take account of sampling methods. Univariate and multivariate analyses were conducted to explore factors associated with contraceptive use.

RESULTS

Two thirds of all women reported having ever been sexually active and among these 87% were sexually active in the past 12 months. Among women who reported currently being sexually active, 52.2% reported using contraceptives. There was evidence of association between contraceptive use and being employed or a student (vs unemployed); fewer sex partners; type of last sex partner; having talked to last partner about condom use and having ever been pregnant.

CONCLUSION

Specific emphasis must be placed on encouraging young women to use contraceptive methods that offer protection against pregnancy and STIs/HIV. Our consistent finding of a relationship between discussing condom use with partners and condom use indicates the importance of involvement of male partners in women's contraceptive decisions.

The developmental association of relationship quality, hormonal contraceptive choice and condom non-use among adolescent women

PURPOSE

Consistent condom use is critical to efforts to prevent sexually transmitted infections among adolescents, but condom use may decline as relationships and contraceptive needs change. The purpose of this research is to assess changes in condom non-use longitudinally in the context of changes in relationship quality, coital frequency and hormonal contraceptive choice.

METHODS

Participants were women (aged 14-17 years at enrollment) recruited from three urban adolescent medicine clinics. Data were collected at three-month intervals using a face-to-face structured interview. Participants were able to contribute up to 10 interviews, but on average contributed 4.2 interviews over the 27-month period. Independent variables assessed partner-specific relationship quality (five items; scale range 5-25; alpha = .92, e.g., this partner is a very important person to me); and, number of coital events with a specific partner. Additional items assessed experience with oral contraceptive pills (OCP) use and injected depo medroxy-progesterone acetate (DMPA). The outcome variable was number of coital events without condom use during the past three months. Analyses were conducted as a three-level hierarchical linear growth curve model using HLM 6. The Level 1 predictor was time, to test the hypothesis that condom non-use increases over time. Level 2 predictors assessed relationship quality and coital frequency across all partners to assess hypotheses that participants' condom non-use increases over time as a function of relationship quality and coital frequency. Level 3 predictors assessed the participant-level influence of OCP or DMPA experience on time-related changes in condom non-use.

RESULTS

A total of 176 women reported 279 sex partners and contributed 478 visits. Both average coital frequency and average condom non-use linearly increased during the 27-month follow-up. At any given follow-up, about 35% reported recent OCP use, and 65% reported DMPA use. HLM analyses showed that condom non-use increased as a function of time (beta = .12; p = .03, Level 1 analysis). Increased condom non-use over time was primarily a function of increased coital frequency (beta = .01; p = .00), although higher levels of relationship quality were associated with increased condom non-use at enrollment (beta = .44; p = .00, Level 2 analysis). The temporal rise in condom non-use significantly increased among DMPA users (beta = .06; p = .00) but not OCP users (Level 3 analysis) (beta = -.04; p = .06).

CONCLUSIONS

Developmentally, relationship characteristics and coital frequency appear to have increasing weight in decisions about condom use. Hormonal contraceptive methods are not equivalently associated with the overall temporal decline in condom use. Future research associated with dual contraceptive/condom use should address differential factors associated condom use in combination with different hormonal methods.

Contraceptive behaviors in adolescents

A wide range of factors influence adolescents' contraceptive behaviors, from personal characteristics to family context to social support to knowledge about and access to contraception. Improving knowledge about contraception and counseling about successful contraceptive use can be helpful in decreasing the remarkably high US rates of adolescent pregnancy. Encouraging the postponement of sexual activity until an individual adolescent is developmentally capable of participating in a mature, healthy, mutually respectful relationship that incorporates effective contraception clearly is a goal that most clinicians, parents, teachers, and other responsible adults can support. Contraceptive technologies that incorporate delivery systems that are "user-friendly" and long-acting also will help to further lower US adolescent pregnancy rates that, while improving, are currently among the highest in the world.