Contraceptive Research and Development Looking to the Future (1996) / Chapter Skim
Currently Skimming:
3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods
3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods
Pages 47-93
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From page 47... ...
The debate is, however, far from an arid academic exercise: Its results have always been significant for the design, implementation, and evaluation of family planning programs. Because the terminology debate is vitally connected to the commodities, that is, the fertility regulation technologies that are essential to family planning, it has large and necessary implications for the pace and direction of contraceptive research and development, as well as for the involvement of industry in R&D processes.
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From page 48... ...
"Specific needs" include sexually transmitted reproductive tract infections; lack of involvement of males in contraception; and contraceptive failure and side effects. Figure 2-1 presents this breakdown in graphic form.
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From page 49... ...
In this framework, the populations that are germane to conceptualizing the market for the outputs from contraceptive research and development are 1. the population that (a)
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From page 50... ...
lives, nor to the statistical realities concerning contraceptive utilization, effectiveness, and appropriateness. The expanded definition adds to the basic conventional definition the following population groups: • sexually active, unmarried women; • women with postpartum amenorrhea; • women who are using a less effective contraceptive method but who definitely want to avoid or postpone childbearing; • women who are using a more effective method but who are using it incorrectly, are dissatisfied, or should not be using it for health reasons; • women with unwanted pregnancies; and • women with related reproductive health problems (Dixon-Mueller and Germain 1994)
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From page 51... ...
As suggested at the beginning of this chapter, there are two very different subpopulations to be accounted for: Subpopulation 1, consisting of those able and willing to spend their own resources; and Subpopulation 2, consisting of those for whom some third party is prepared to pay. This latter, "third-party" category contains considerable variety: private insurance companies, managed care organizations, hybrid network arrangements, and government programs for the poor in the United States and other developed nations, as well as national family planning and public health sector programs in develop
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From page 52... ...
AGI (1995) Includes Population Include as Having an as Having an Unmet Assumptions Underlying Characteristics Unmet Need for Contraception: Need for Contraception: AGI Calculations Union status All women currently in union All women of reproductive age Many single women also have a need to avoid pregnancy Age Aged 15–49 Aged 15–44 Women aged 45–49 are probably infecund in any event Pregnancy All women who did not want All women who do not want Some women are unable to use any most recent pregnancy and were current pregnancy, whether or method effectively or are using a not contracepting at time of not contracepting at time of method with high failure rates that conception that conception Amenorrhea All women who did not want All women who do not want All have a need even if, technically, postpartum most recent pregnancy and were another child, soon or ever, they cannot conceive at the moment not contracepting at the time and are not using an effective of that conception method of contraception Use of Women using postpartum Although the abstinence may not be postpartum abstinence intended to prevent pregnancy, it abstinence nonetheless has assured contraceptive effect, so that women maintaining postpartum abstinence are not in need Method use Women using traditional Traditional methods can have high methods of contraception failure rates and thus do not offer (rhythm, withdrawal, etc.)
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From page 53... ...
SOURCES: Alan Guttmacher Institute (AGI)
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From page 54... ...
These shared unmet needs include unintended pregnancy, abortion, maternal mortality and morbidity, and sexually transmitted disease, needs which can be especially acute and especially costly in populations of particular vulnerability owing to such covariates as age, parity, ethnicity, or socioeconomic status.
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From page 55... ...
We will argue in Chapter 5 that contraception that includes or is accompanied by protection against sexually transmitted diseases is even more cost-effective and surely risk-reducing. As more and more third-party payers assume long-term responsibility for covering large, stable populations over a long period of time for a broad range of health care services, it is reasonable to assume that they will look to those savings that can be derived from prevention and, therefore, see the economic value and consequent logic of substantially increasing their investment in contraceptive and reproductive health services as a major cost-containment tool.
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From page 56... ...
, many women will still require protection from sexually transmitted infection, as is increasingly the case for many women throughout their reproductive years (Forrest 1993)
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From page 57... ...
Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute.
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From page 58... ...
The table includes the postmenopausal years even though this period lies beyond what are biomedically defined as the reproductive years, since many women continue to be sexually active; because of menopauseassociated physiological changes (e.g., structural changes in vaginal tissues) , those women remain vulnerable to sexually transmitted infections.
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From page 59... ...
However, the NSFG has developed very specific terminology and definitions to measure "unintended pregnancy," using the following definitions of "intended" and "unintended": • intended at conception: wanted at the time, or sooner, irrespective of whether or not contraception was being used; or • unintended at conception: if a pregnancy had not been wanted at the time conception occurred, irrespective of whether or not contraception was being used. Among unintended pregnancies, a further distinction is made between mistimed and unwanted: • mistimed conceptions are those that were wanted by the woman at some time, but which occurred sooner than they were wanted; and • unwanted conceptions are those that occurred when the woman did not want to have any more pregnancies at all (IOM 1995)
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From page 60... ...
60 CONTRACEPTIVE RESEARCH AND DEVELOPMENT TABLE 2-3 Life Span Factors in Women's Reproductive Lives Stage 1 Stage 2 Menarche–Intercourse Intercourse–Marriage Biologic variables Menarche First intercourse High reproductive capacity High risk of exposure to STDs High risk of unintended pregnancy High maternal/child mortality and morbidity from too-early pregnancy Social variables Politically most Politically contentious contentious stage Laws governing age at marriage Restricted provision of family Restricted provision of family planning services planning services Constrained access to information about sexuality and contraception Psychological Limited future orientation/ Constrained ability to variables ability to judge risks/conse- negotiate use of coitus quences/defer gratification related methods Heightened sense of unique Ambivalence invulnerability Need to establish adult identity/peer intimacy Constrained ability to negotiate use of coitus related methods Ambivalence Fertility goals: Childbearing Postpone Postpone Future fertility Preserve Preserve (high need)
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From page 61... ...
NEED AND DEMAND FOR NEW CONTRACEPTIVE METHODS 61 Stage 4 Stage 3 1st Birth–Attainment of Stage 5 Stage 6 Marriage–1st Birth Desired Family Size Menopause Postmenopause Marriage Intend no more children Sterility/infertility High reproductive High reproductive capacity capacity Possible fetal wastage/ectopic pregnancy/infertility Increased incidence and severity of many gynecologic problems Parity requirements for Irrelevant sterilization Greater intellectual/ Heightened maturity emotional maturity/ ability to judge consequences Postpone Space Stop Preserve (high need) Preserve (diminishing Irrelevant need)
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From page 62... ...
Safety during High High breastfeeding NOTE: STDs = sexually transmitted diseases. SOURCES: Modified from Forrest JD, Timing of reproductive stages, American Journal of Obstetrics and Gynecology 82:110, 1993, and Hatcher RA, J Trussell, F Stewart, et al.
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From page 63... ...
Moderate Irrelevant Irrelevant Technology, 16th revised ed., New York, Irvington Publishers, 1994. We have added Stage 6, the postmenopausal period, since many women remain sexually active despite termination of fertility, and may require protection from sexually transmitted infections.
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From page 64... ...
Source: Alan Guttmacher Institute. Women, Families, and the Future: Women and Reproductive Health (Regional Fact Sheet)
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From page 65... ...
That graphic was, in turn, constructed from the following sources: For the developing regions of the world, the number of abortions and live births: Alan Guttmacher Institute, Women, Families and the Future, New York, 1995. For China, the number of abortions: Henshaw SK, Induced abortion: A world review, Family Planning Perspectives 22:76–89, 1990; the number of live births: United Nations, World Population Prospects: The 1994 Revision, New York, 1995.
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From page 66... ...
66 TABLE 2-5 Planning Status, Last Birth, and Preferences for Next Birth (selected countries, various survey years) Average Number of Children % Whose Last Birth Was Unplanned % Who Want to Stop or Postpone Country and Survey Year Wanted Havea "GAP" Mistimedb Unwantedc TOTAL Stopd Postponee TOTAL Cameroon, 1991 6.7 5.5 – 17 5 22 45 14 59 Nigeria, 1990 5.9 6.2 + 9 3 12 53 9 62 Pakistan, 1990–1991 5.3 5.9 + 8 16 24 21 40 61 Jordan, 1990 4.9 5.4 + 12 26 38 28 53 81 Guatemala, 1987 4.2 5.1 + 16 13 29 40 47 87 Kenya, 1993 3.8 6.0 ++ 36 20 56 33 52 85 Egypt, 1992 3.5 3.7 + 9 33 42 19 67 86 Indonesia, 1991 3.4 2.8 – 16 8 24 32 54 86 Mexico, 1987 3.2 3.0 – 24 27 51 18 62 80 Philippines, 1992 3.2 3.8 + 26 21 47 25 63 88 CONTRACEPTIVE RESEARCH AND DEVELOPMENT
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From page 67... ...
SOURCE: Derived from Appendix Table 5 (Columns 1 and 5, 18 and 19, and 20 and 21) , Alan Guttmacher Institute, Hopes and Realities: Closing the Gap NEED AND DEMAND FOR NEW CONTRACEPTIVE METHODS Between Women's Aspirations and Their Reproductive Experience, New York, The Alan Guttmacher Institute, 1995.
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From page 68... ...
In the North Africa–Middle East region, close to half of recent births were unwanted, with most of that percentage deriving from unwanted rather than mistimed births. The highest regional abortion rates were in South and Southeast Asia, where 18 percent of all recent births were so terminated.
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From page 69... ...
First of all, women of all socioeconomic, marital-status, and age groups contribute to the pool of unintended pregnancies; adults as well as teenagers are having difficulty planning and preventing pregnancy. Second, although marital status, which is highly correlated with age, is also strongly related to whether a pregnancy is unintended, 4 out of 10 pregnancies among currently married women were either
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From page 70... ...
Percentage of Unintended Intended Unintended Percentage of Pregnancies Demographic Total Pregnancies Pregnancies Pregnancies Ending in Characteristics Pregnancies Ending in Births Ending in Births Abortions Unintended Abortion Total 100.1 42.8 28.4 28.9 57.3 50.4 Marital status Currently married 100.0 59.9 29.7 10.4 40.1 25.9 Formerly married 100.0 31.5 32.4 36.1 68.5 52.7 Never married 100.0 11.8 22.0 66.2 88.2 75.1 Age 15–19 100.0 18.3 40.0 41.7 81.7 51.0 20–24 100.0 39.4 29.7 30.9 60.6 51.0 25–29 100.0 54.8 23.8 21.4 45.2 47.3 30–34 100.0 57.9 21.0 21.1 42.1 50.1 35–39 100.0 44.1 25.1 39.7 55.9 55.1 40–44 100.0 23.1 31.3 45.6 76.9 59.3 Poverty Status <100% 100.0 24.6 35.6 39.8 75.4 52.8 100–199% 100.0 36.0 26.8 37.2 64.0 58.1 >200% 100.0 55.0 25.7 19.3 45.0 42.9 SOURCE: Institute of Medicine, The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families, S Brown, L Eisenberg, eds., CONTRACEPTIVE RESEARCH AND DEVELOPMENT Washington, DC: National Academy Press, 1995, based on: Forrest JD, Epidemiology of unintended pregnancy and contraceptive use, American Journal of Obstetrics and Gynecology 170:1485–1488, 1994.
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From page 71... ...
It also addresses the matter of the sexually transmitted diseases as a correlate of sexual activity that, more and more, must be taken into account in thinking about women's reproductive health in general and contraception in particular. Abortion Everywhere in the world, unintendedness in pregnancy is the antecedent of virtually all induced abortions (Chen 1995)
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From page 72... ...
. Not surprisingly, the complications of unsafe abortions are a leading cause of maternal deaths, over 98 percent of which occur in the developing world, where they account for around 13 percent (1 in 8)
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From page 73... ...
Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, 2nd ed. Geneva: Division of Family Health.
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From page 74... ...
Infections may spread throughout the reproductive tract and produce acute pelvic inflammatory disease (PID) , with tubal damage, secondary infertility, predisposition to ectopic pregnancy, chronic pain, and, in severe cases, formation of abdominopelvic abscess requiring emergency surgery and occasionally resulting in death (Meheus 1992)
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From page 75... ...
Fifty-one percent of unintended pregnancies among women aged 15–19 and women aged 20–24 end in abortion, then there is a slight decline to 47 and 50 percent in women aged 25–29 and 30–34, respectively. The rates jump to 55 percent in women aged 35–39 and to 59 percent in women aged 40–44; in other words, about 6 out of 10 women aged 40– 44 who experience an unintended pregnancy seek abortion.
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From page 76... ...
women in every age and socioeconomic category terminate unintended pregnancies with abortion; even among currently married women, that proportion is still 26 percent. Maternal Mortality Significant gains have been made in infant and child survival in developing countries over the past few decades; much less progress has been made in maternal survival (Rosenfield and Maine 1985)
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From page 77... ...
Induced Abortion: A World Review, 1990 Supplement. New York: The Alan Guttmacher Institute, 1990.
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From page 78... ...
. Sexually Transmitted Reproductive Tract Infections Of all the health problems that women confront, infection of the reproductive tract is most closely connected with family planning programs.
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From page 79... ...
Sexually transmitted diseases. IN Reproductive Health Care for Women and Babies: Analysis of Medical, Economic, Ethical, and Political Issues, BP Sachs, R Beard, et al., eds.
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From page 80... ...
At the present time, only abstinence provides complete protection against sexually transmitted reproductive tract infections.15 Male and female condoms, when used properly, also provide good protection, although many women encounter male resistance to using either type of condom. All other contraceptives
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From page 81... ...
. INVOLVEMENT OF MALES IN CONTRACEPTION The Alan Guttmacher Institute recently commented that, since men's role in contraceptive use is so typically small, the question about what couples are doing to avoid unintended pregnancies should be, What are women doing?
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From page 82... ...
Hope and Realities: The Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute.
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From page 83... ...
. The rationales include the need to include male partners in STD testing, treatment, and education; adding services for men as part of managed care marketing strategies; and the national emphasis on male responsibility in welfare and child support enforcement programs, an integral part of every welfare reform program currently under consideration by the U.S.
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From page 84... ...
Kenya, 1989 1,170 95 91 65 35 65 25 49 -- -- -- CONTRACEPTIVE RESEARCH AND DEVELOPMENT
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From page 85... ...
Data for Morocco and Niger are from Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, The Alan Guttmacher Institute, 1995.
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From page 86... ...
And very large numbers of women, even those who have not yet achieved their desired family size, nonetheless state that they failed in their intentions with regard to their last pregnancy, either because they did not mean to have it at all or because they meant to have it at some later date. Another dimension of general need is the sheer number of years women require protection from unintended pregnancy since, somewhat ironically, as completed family size continues to fall worldwide, women's lifetime exposure increases; a woman who wants only two children will require 20 years of protec
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From page 87... ...
This means that, for a number of reasons, the same contraceptive is unlikely to be appropriate for an ever-longer and more biologically various life span, thus requiring a more various set of contraceptive alternatives. Ancillary analyses tell us about other aspects of the general need for contraception.
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From page 88... ...
Sexually transmitted diseases: Current and future dimensions of the problem in the Third World. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health.
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From page 89... ...
Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. New York: Plenum.
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From page 90... ...
Women's health: Importance of reproductive tract infections, pelvic inflammatory dis ease and cervical cancer. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health.
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From page 91... ...
Epidemiological synergy: Interrelationships between human immunodeficiency vi rus infection and other sexually transmitted diseases. IN AIDS and Women's Health: Science for Policy and Action.
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From page 92... ...
7. The sections of this report dealing with unintended pregnancy have relied heavily on the exhaustive analysis of the Demographic and Health Surveys and other national surveys by The Alan Guttmacher Institute, partly in preparation for its recently released study, Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences (1995)
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From page 93... ...
have been broadly defined to include sexually transmitted infections and infections that are nonsexually transmitted, and comprise three types of infection: (1) sexually transmitted diseases (STDs)
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