An "Imperfect" Contraceptive Society: Fertility and Contraception in Italy

Declining fertility and increasing use of traditional methods of family planning: a paradox in Uttar Pradesh, India?

Uttar Pradesh (UP), with more than 220 million people, is the most populous state in India. Despite a high unmet need for modern family planning methods, the state has experienced a substantial decline in fertility. India has also seen a decline during this period which can be attributed to the increased prevalence of modern methods of family planning, particularly female sterilisation, but in UP, the corresponding increase was marginal. At the same time, Traditional Family Planning Methods (TMs) increased significantly in UP in contrast to India, where it was marginal. The trends in UP raise questions about the drivers in fertility decline and question the conventional wisdom that fertility declines are driven by modern methods, and the paper aims to understand this paradox. Fertility trends and family planning practices in UP were analysed using data from different rounds of National Family Health Surveys (NFHS) and the two UP Family Planning Surveys conducted by the UP Technical Support Unit to understand whether the use of TMs played a role in the fertility decline. As per NFHS-4, the prevalence of TM in India (6%) was less than half that of UP (13%). The UP Family Planning Survey in 25 High Priority Districts estimated that 22% of women used TMs. The analysis also suggested that availability and accessibiility of modern contraceptives might have played a role in the increased use of TMs in UP. If there are still couples who make a choice in favour of TMs, they should be well informed about the risks associated with the use of traditional methods as higher failure rate is observed among TMs users.

Demographic Anxiety and Abortion: Italian Pro-Life Volunteers' and Gynecologists' Perspectives

In this article, we analyze the public debate on fertility decline and abortion in Italy, focusing on demographic anxieties, fueled by conservative demographers and politicians, about the different reproductive behavior of native Italians and migrants. We argue that vitapolitics, a moral regime that defends "life" and condemns abortion, is one of the main mechanisms of reproductive governance in Italy. Drawing on two studies 1) on pro-life volunteers' activism and 2) gynecologists' attitudes to abortion and conscientious objection, we illustrate how vitapolitics shapes the demographic anxieties of these two social actors, who contribute to discipline reproduction on the ground.

Cross-border reproductive healthcare attitudes and behaviours among women living in Florence, Italy

BACKGROUND

The number of women living in Italy and seeking cross-border reproductive care (CBRC), especially for medically assisted reproduction (MAR), has increased. The purpose of this study was to explore CBRC attitudes and behaviours among a cohort of reproductive-aged women who have never engaged in CBRC to gauge social and cultural perceptions and gain a deeper understanding of family planning discourse.

METHODS

In-depth interviews were conducted during May - June 2018 with 30 women aged 18-50 living in or around Florence, Italy and enrolled in the Italian healthcare system. Interviews offered in-depth insight into CBRC attitudes, behaviours, and experiences among a cohort of women living in Italy who had never engaged in CBRC. Researchers used an expanded grounded theory through open and axial coding. Emergent themes were identified via a constant comparison approach.

RESULTS

Three themes and two subthemes emerged from the data. Participants discussed how limitations in Italy's access to MAR can lead women to seek reproductive healthcare in other countries. Women had mixed feelings about the effect of religion on legislation and reproductive healthcare access, with many views tied to religious and spiritual norms impacting MAR treatment-seeking in-country and across borders. Participants perceived infertility and CBRC-seeking as socially isolating, as the motherhood identity was highly revered. The financial cost of traveling for CBRC limited access and exacerbated emotional impacts.

CONCLUSIONS

Findings offered insight into CBRC perceptions and intentions, presenting a deeper understanding of the existing family planning discourse among reproductive-aged women. This may allow policymakers and practitioners to address social and cultural perceptions, increase access to safe and effective local care, and empower women in their family planning decisions.

Real world utilization of 91 day extended levonorgestrel-containing combined oral contraceptives in Europe: a multinational database study

OBJECTIVE

As part of the risk management plan in Europe, this study was conducted to characterize drug utilization patterns of Seasonique, a 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG).

METHODS

A retrospective observational study was conducted in France, Italy and Belgium using electronic medical record databases obtained from general practitioners (GPs) in all participating countries and gynecologists in France from 2015 to 2018. The study population included women receiving ≥1 prescription of 91 day COC_LNG during the study period. Prescribing patterns of 91 day COC_LNG were examined including: (1) treatment duration; (2) indication; (3) use of combined oral contraceptive (COC) before 91 day COC_LNG initiation; and (4) switch from and to combined hormonal contraceptives (CHCs) or other contraceptives.

RESULTS

Totals of 235, 220, 207 and 659 women using 91 day COC_LNG were identified in French, Italian and Belgian GP, and French gynecologist databases, respectively. Across databases, 46-76% of women were prescribed a single 91 day COC_LNG prescription and median treatment duration ranged from 3 to 6 months. The most common indication was contraception (42-81%), followed by menstrual migraines (2-14%). Use of COC during the 6 months prior to 91 day COC_LNG initiation was 14% across GP databases, but was lower (8%) in the French gynecologist database. The frequency of switching from 91 day COC_LNG to CHCs or other contraceptives was generally low (5-12%), with the highest proportion being among patients of French gynecologists.

CONCLUSIONS

Findings indicate that 91 day COC_LNG was prescribed for relatively short durations and predominantly as indicated for contraception. Most results were comparable across all participating countries. KEY POINTSFindings from this drug utilization study in European databases across general practitioners and French gynecologists confirmed that 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG) was prescribed for relatively short durations (median 3-6 months); predominantly for the intended indication of contraception.Combined oral contraceptive use during the 6 months prior to 91 day COC_LNG initiation, and switching from 91 day COC_LNG to combined hormonal contraceptives or other contraceptives, were generally low (14% or less).These findings were mostly consistent across participating countries.

Translating policy to practice: theory-based formative research to improve messaging and over-the-counter access to emergency contraception in Florence, Italy

OBJECTIVES

Italy's 2015 emergency contraception (EC) policy made EC available without prescription for individuals aged 18 years and older; however, women living in Italy continue to face barriers to accessing EC. The purposes of this study were to understand EC knowledge, attitudes and behaviours among women living in Italy and explore the impact of the 2015 policy.

METHODS

Researchers conducted 30 interviews with women living in Florence, Italy, aged 18-50 years and using the Italian health care system. Researchers used an expanded grounded theory approach to understand women's EC experiences, with diffusion of innovations (DOI) serving as a conceptual lens. Researchers completed open and axial coding to identify emerging themes.

RESULTS

Participants had low awareness of the 2015 EC policy and suggested increased messaging in strategic locations to overcome this barrier. They held positive and negative attitudes towards EC: while some perceived the advantage of EC compared with unintended pregnancy, others expressed concerns about irresponsible behaviour and safety. Finally, conscientious objection impacted access, despite women's desire for autonomous EC decision making.

CONCLUSION

The findings offer practical recommendations to guide EC messaging in Italy to increase women's access to EC. Recommendations include using theory- and audience-based methods to overcome gaps in policy knowledge and real and perceived barriers to EC access. Incorporating DOI as a theoretical framework with women's voices presents a novel opportunity to enhance policy and EC dissemination.

"It's not perfect but it's mine": Genital self-image among women living in Italy

The purpose of this article is to describe Italian women's attitudes toward their genitals, and the intersection of genital self-image (GSI) and reproductive and sexual health behaviors. Individual interviews were conducted with 46 reproductive-aged women. All interviews were transcribed verbatim with observer comments to identify emerging data patterns. Researchers completed coding between and within interviews for a constant comparative approach to data analysis to identify emergent themes. Participants expressed embarrassment discussing genitals and equated this with societal taboos; however, friends provided one opportunity to speak more openly. Odor discussions and hygiene practices were frequently occurring themes, especially during menstruation. GSI limited some daily activities and sexual experiences due to feelings of self-consciousness. Concerns stemmed from limited knowledge about how women's genitals should look, smell, and feel. In contrast, some women detailed positive GSI in terms of autonomy and self-care. Results illustrate practical recommendations for healthcare providers to address women's genital concerns and improve women's GSI and overall reproductive and sexual health experiences.

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

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

Psychometric Evaluation of an Instrument to Measure Prospective Pregnancy Preferences: The Desire to Avoid Pregnancy Scale

BACKGROUND

Existing approaches to measuring women's pregnancy intentions suffer important limitations, including retrospective assessment, overly simple categories, and a presumption that all women plan pregnancies. No psychometrically valid scales exist to prospectively measure the ranges of women's pregnancy preferences.

MATERIALS AND METHODS

Using a rigorous construct modeling approach, we developed a scale to measure desire to avoid pregnancy. We developed 60 draft items from existing research, assessed comprehension through 25 cognitive interviews, and administered items in surveys with 594 nonpregnant women in 7 primary and reproductive health care facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used item response theory to reduce the item set and assess the scale's reliability, internal structure validity, and external validity. Items were included based on fit to a random effects multinomial logistic regression model (partial credit item response model), correspondence of item difficulty with participants' pregnancy preference levels, and consistency of each item's response options with overall scale scores.

RESULTS

The 14 final items covered 3 conceptual domains: cognitive preferences, affective feelings, and practical consequences. Items fit the unidimensional model, with a separation reliability of 0.90 (Cronbach α: 0.95). The scale met established criteria for internal validity, including correspondence between each item's response categories and overall scale scores. We found no important differential item functioning by participant characteristics.

CONCLUSIONS

A robust measure is available to prospectively measure desire to avoid pregnancy. The measure can aid in identifying women who could benefit from contraceptive care and research on less desired pregnancy.

Ready, Willing, and Able: Contraceptive Use Patterns Across Europe

An "East-West" divide in contraceptive use patterns has been identified across Europe, with Western European countries characterized by the widespread use of modern contraception, and Central and Eastern European countries characterized by a high prevalence of withdrawal, the rhythm method, or abortion. Building on the Ready-Willing-Able framework, this study aims to gain more insight into the micro- and macro-level socioeconomic, cultural, and technological determinants underlying contraceptive use. Data from the Generations and Gender Survey (2004-2011) covering four Western and seven Central and Eastern European countries are used, and multinomial multilevel analyses are performed. Results reveal that individuals who intend to delay parenthood are more likely to use any contraceptive method, whereas holding more traditional values and having a lower socioeconomic status are associated with a higher likelihood of using no or only traditional methods. Regional reproductive rights and gender equality interact in complex ways with these associations. At minimum, our results underline the complexity of the processes underlying the persistent difference in contraceptive use across Europe.

Use of traditional contraceptive methods in India & its socio-demographic determinants

BACKGROUND & OBJECTIVES

The high use of traditional contraceptive methods may have health repercussions on both partners. High failure rate, lack of protection from sexually transmitted diseases are some of the examples of these repercussions. The aim of this study was to understand the level, trends, pattern, volume and socio-demographic determinants of using traditional contraceptive methods in the Indian context.

METHODS

Percentages, per cent distribution, cross-tabulation and multinomial logistic regression analyses were carried out. The data from the three rounds of National Family Health survey (NFHS) were used. The unit level District Level Household Survey (2007-2008) were mainly used to carry out the analysis in this paper. Marriage rates for States and Union Territories (UTs) were projected for the period of 2001-2011 to estimate the volume of traditional contraceptive users. These rates are required to get the number of eligible couples as on 2011 in the respective State/UT.

RESULTS

The latest round of the District Level Household Survey (2007-2008) revealed that 6.7 per cent currently married women were using traditional contraceptive methods in India. More than half of the currently married women (56%) have ever used these methods. In terms of socio-demographic determinants, the odds ratios of using these methods were significantly higher for women aged 35 years and above, rural, Hindu, other than Scheduled Castes/Tribes (SCs/STs), secondary and above educated, non-poor, having two plus living children, and at least one surviving son in most of the states as well as at the national level. The northeastern region showed higher odds ratios (5 times) of women using traditional contraceptive methods than the southern region.

INTERPRETATION & CONCLUSIONS

A large number of currently married women have ever used the traditional contraceptive methods in India. On the basis of the findings from this study, the total size of those women who were using traditional methods and those who were having unmet need, and are required to use modern spacing methods of family planning in achieving the reproductive goals, is around 53 million. Women from a set of specific socio-demographic backgrounds are more likely to use these methods. A regional pattern has also emerged in use of tradition contraceptive methods in India.

Effects of combined hormonal contraception on health and wellbeing: women's knowledge in northern Italy

OBJECTIVES

We investigated levels of knowledge of the effects of combined hormonal contraceptives (CHCs) on general/reproductive health and physical/psychosexual wellbeing.

METHODS

A cross-sectional study was conducted in two university hospitals in northern Italy. Healthy current-, past- and never CHC users (n = 545; age 18-44 years) completed a self-administered questionnaire.

RESULTS

Ninety-three percent of current-, 74% of past-, and 56% of never users believed they were sufficiently informed (χ(2): 67.1; p = 0.001) about the benefits and risks of CHCs. Respondents mentioned: (i) a reduced risk of ovarian (67%) and endometrial (53%) cancer; (ii) an increased risk of thrombosis (82%); (iii) an increased risk of breast cancer (45%); (iv) a decreased fertility (19%) and no influence on risk of sexually transmitted infections (48%); (v) a reduced risk of menstrual abnormalities (77%) and acne (79%); (vi) less dysmenorrhoea (83%) and more headache (56%), weight gain (74%), increased appetite (51%), leg cramps (77%), mood swings (45%), vaginal dryness (47%), and low sex drive (48%). Beliefs about diseases/conditions and symptoms were influenced by CHC use.

CONCLUSIONS

CHC use is linked to good knowledge of risks and benefits. Our data suggest HCPs must be proactive in providing relevant information so that women can choose their contraception with a balanced insight of side effects.

Determinants of emergency contraception non-use among women in unplanned or ambivalent pregnancies

Objective To analyze the determinants of emergency contraception non-use among women in unplanned and ambivalent pregnancies. Method Cross-sectional study with a probabilistic sample of 366 pregnant women from 12 primary health care units in the city of São Paulo, Brazil. A multinomial logistic regression was performed, comparing three groups: women who used emergency contraception to prevent ongoing pregnancies (reference); women who made no use of emergency contraception, but used other contraceptive methods; and women who made no use of any contraceptive methods at all. Results Cohabitation with a partner was the common determinant of emergency contraception non-use. No pregnancy risk awareness, ambivalent pregnancies and no previous use of emergency contraception also contributed to emergency contraception non-use. Conclusion Apart from what is pointed out in the literature, knowledge of emergency contraception and the fertile period were not associated to its use.

Space, agency, and withdrawal: birth control choices of women in Turkey

Withdrawal (WD) is not a reliable method for preventing unwanted pregnancies, yet it is still a very popular form of birth control in many societies, including Turkey. We look at the relationship between women's agency and physical space in relation to birth control choices of women in Turkey. Agency in our context refers to a woman's ability to resist domination and subordination to the patriarchal beliefs valuing her reproductivity over her pleasure. Our analysis of the Turkish Demographic Health Survey (TDHS) suggests that (a) the available space in the household for possible private encounters between husband and wife, and (b) the women's capacity to insert her agency into her life choices are closely correlated with WD choices. Women with better social and physical resources prefer WD less.

Measuring pregnancy planning: An assessment of the London Measure of Unplanned Pregnancy among urban, south Indian women

We evaluated the psychometric properties of the London Measure of Unplanned Pregnancy among Indian women using classical methods and Item Response Modeling. The scale exhibited good internal consistency and internal structure, with overall scores correlating well with each item's response categories. Items performed similarly for pregnant and non-pregnant women, and scores decreased with increasing parity, providing evidence for validity. Analyses also detected limitations, including infrequent selection of middle response categories and some evidence of differential item functioning by parity. We conclude that the LMUP represents an improvement over existing measures but recommend steps for enhancing scale performance for this cultural context.