Married adolescents: An overview

The nascent work reviewed in this compendium indicates that married girls experience significant social isolation and limited autonomy. Across the studies examined, on indicators of mobility, exposure to media, and social networks, married girls are consistently disadvantaged compared to their unmarried peers. Similarly, across studies, on most of the domains explored here (mobility, decision-making, control over economic resources, and possibly gender-based violence), married girls tend to be less empowered and more isolated than slightly older married females. There may also be health issues associated with marriage during adolescence. Married girls are frequently at a disadvantage in terms of reproductive health information—particularly regarding STIs and HIV. First-time mothers, many of whom are adolescents, by virtue of their parity may have distinct maternal health needs and risks. Finally, early marriage potentially plays a role in exposing girls and young women to severe reproductive health risks, including HIV. Many of these elevated health risks may be largely, though not exclusively, derivative of their social vulnerability

A world apart: The disadvantage and social isolation of married adolescent girls

This brief is based on a paper prepared for the WHO/UNFPA/Population Council Technical Consultation on Married Adolescents, held in Geneva, Switzerland, December 9–12, 2003. The consultation brought together experts from the United Nations, donors, and nongovernmental agencies to consider the evidence regarding married adolescent girls’ reproductive health, vulnerability to HIV infection, social and economic disadvantage, and rights. The relationships to major policy initiatives—including safe motherhood, HIV, adolescent sexual and reproductive health, and reproductive rights—were explored, and emerging findings from the still relatively rare programs that are directed at this population were discussed. Despite the program attention and funding that have been devoted to adolescents, early marriage and married adolescents have fallen largely outside of the field’s concern. Comprising the majority of sexually active adolescent girls in developing countries, this large and vulnerable subpopulation has received neither program and policy consideration in the adolescent sexual and reproductive health field, nor special attention from reproductive health and development programs for adult women. While adolescent girls, irrespective of marital status, are vulnerable in many settings and deserve program, policy, and resource support, the purpose of this brief is to describe the distinctive and often disadvantaged situations of married girls and to propose possible future policy and program options

Policy maker and health care provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa

Background: Worldwide there is growing attention paid to the reproductive decisions faced by HIV-infected individuals. Studies in both developed and developing countries have suggested that many HIV-infected women continue to desire children despite knowledge of their HIV status. Despite the increasing attention to the health care needs of HIV-infected individuals in low resource settings, little attention has been given to reproductive choice and intentions. Health care providers play a crucial role in determining access to reproductive health services and their influence is likely to be heightened in delivering services to HIV-infected women. We examined the attitudes of health care policy makers and providers towards reproductive decision-making among HIV-infected individuals. Methods: In-depth interviews were conducted with 14 health care providers at two public sector health care facilities located in Cape Town, South Africa. In addition, 12 in-depth interviews with public sector policy makers and managers, and managers within HIV/AIDS and reproductive health NGOs were conducted. Data were analyzed using a grounded theory approach. Results: Providers and policy makers approached the issues related to being HIV-infected and child bearing differently. Biomedical considerations were paramount in providers' approaches to HIV infection and reproductive decision-making, whereas, policy makers approached the issues more broadly recognizing the structural constraints that inform the provision of reproductive health care services and the possibility of "choice" for HIV-infected individuals. Conclusion: The findings highlight the diversity of perspectives among policy makers and providers regarding the reproductive decisions taken by HIV-infected people. There is a clear need for more explicit policies recognizing the reproductive rights and choices of HIV-infected individuals

Unwanted pregnancy and induced abortion: Data from men and women in Rajasthan, India

This report is the result of a collaborative project between the Population Council and the Centre for Operations Research and Training, conducted as part of a Council program of research on unwanted pregnancy and induced abortion in Rajasthan, India. Designed as a complement to service-delivery activities being undertaken in Rajasthan by the Indian nongovernmental reproductive health service provider Parivar Seva Sanstha, the program of research aimed to provide a multifaceted picture of the on-the-ground realities related to unwanted pregnancy and abortion in six districts of Rajasthan. Detailed pregnancy histories yielded data on levels of unwanted pregnancy and induced abortion in the sampled areas in Rajasthan. As noted in this report, the legal right to abortion is not a reality for the majority of women in the sample in Rajasthan. Women have strong desires to meet their reproductive intentions, but existing methods of family planning and abortion services are not meeting their needs. According to the report, public information campaigns to educate women, their spouses, and other family members about the legal right to abortion, as well as efforts to revise the Medical Termination of Pregnancy Act, are imperative if access to abortion services is to improve

Unwanted pregnancy and induced abortion in Rajasthan, India: A qualitative exploration

As part of a Population Council program of research on unwanted pregnancy and induced abortion in Rajasthan, the Council and Ibtada conducted a qualitative exploration of attitudes and behaviors regarding unwanted pregnancy and induced abortion in Alwar district. The study was intended to lay the groundwork for two quantitative studies on abortion undertaken subsequently in six districts of Rajasthan. The qualitative exploration shows that women, particularly those who are poor, turn to largely untrained community-level providers for abortion services. Additionally, women use home remedies in an often unsuccessful attempt to terminate unwanted pregnancies. Women with greater financial means obtain surgical services from a private gynecologist. The remaining women are left with little choice but to avail of services from informal providers that they often recognize to be unsafe and/or to carry unwanted pregnancies to term. This report encourages innovative means to improve access to legal, safe, and effective abortion services at lower levels of the public health system, and suggests that the feasibility of training certain informal providers to offer safe abortion services, particularly at early gestations, should be explored at the policy, program, and research levels

Foley catheterisation versus oral misoprostol for induction of labour in hypertensive women in India (INFORM): a multicentre, open-label, randomised controlled trial

Background Between 62 000 and 77 000 women die annually from pre-eclampsia and eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low-cost interventions—low-dose oral misoprostol tablets and transcervical Foley catheterisation—are already used in low-resource settings. We aimed to compare the relative risks and benefits of these interventions. Methods We undertook this multicentre, open-label, randomised controlled trial in two public hospitals in Nagpur, India. Women (aged ≥18 years) who were at 20 weeks' gestation or later with a live fetus and required delivery as a result of pre-eclampsia or hypertension were randomly assigned (1:1), via computer-generated block randomisation (block sizes of four, six, and eight) with concealment by use of opaque, sequentially numbered, sealed envelopes, to receive labour induction with either oral misoprostol 25 μg every 2 h (maximum of 12 doses) or a transcervical Foley catheter (silicone, size 18 F with 30 mL balloon). Randomisation was stratified by study centre. The catheter remained in place until active labour started, the catheter fell out, or 12 h had elapsed. If the catheter did not fall out within 12 h, induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h. Due to the nature of the interventions, masking of participants, study investigators, and care providers to group allocation was not possible. We analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01801410. Findings Between Dec 20, 2013, and June 29, 2015, we randomly assigned 602 women to induction with misoprostol (n=302) or the Foley catheter (n=300; intention-to-treat population). Vaginal birth within 24 h was more common in women in the misoprostol group than in the Foley catheter group (172 [57·0%] vs 141 [47·0%] women; absolute risk difference 10·0%, 95% CI 2·0–17·9; p=0·0136). Rates of uterine hyperstimulation were low in both the misoprostol and Foley catheter groups (two [0·7%] vs one [0·3%] cases; absolute risk difference 0·3%, 95% CI −0·8 to 1·5; p=0·566) and neonatal deaths did not differ significantly between groups (six [2·0%] vs three [1·0%] neonatal deaths; 1·0, −1·04 to 2·97; p=0·322). 17 serious adverse events (3%) were reported during the study: one case of intrapartum convulsion and one case of disseminated intravascular coagulation (both in the Foley group); ten perinatal deaths, including two stillbirths (both in the Foley catheter group) and eight neonatal deaths (n=5 in the misoprostol group and n=3 in the Foley catheter group); and five of neonatal morbidity, comprising birth asphyxia (n=3), septicaemia (n=1), and neonatal convulsion (n=1). Interpretation Oral misoprostol was more effective than transcervical Foley catheterisation for induction of labour in women with pre-eclampsia or hypertension. Future studies are required to assess whether oxytocin augmentation following misoprostol can be replaced by regular doses of oral misoprostol tablets

Formal and informal abortion services in Rajasthan, India: Results of a situation analysis

As part of a Population Council program of research on unwanted pregnancy and induced abortion in Rajasthan, the Population Council and the Centre for Operations Research and Training conducted a situation analysis of abortion services in both the formal and informal sectors in six districts. This report offers insights into the availability and organization of abortion services in the sampled areas in Rajasthan. The report also documents a vast array of informal providers who offer services for delayed menstruation or unwanted pregnancy. Informal providers appear particularly accessible to women because they are far more prevalent in rural areas than formal providers, are generally well known in the community, maintain extended working hours, and sometimes provide care at women’s homes. The findings underscore the need to improve access to affordable, high-quality, legal abortion services, particularly in rural areas. Until this is done, informal providers and uncertified facilities will remain the best option for poor and rural women despite the fact that abortion has been legal in India for over 30 years

Reproductive intentions and choices among HIV-infected individuals in Cape Town, South Africa: Lessons for reproductive policy and service provision from a qualitative study

While many HIV-infected individuals do not wish to have children, others want children despite their infected status. The desire and intent to have children among HIV-infected individuals may increase because of improved quality of life and survival following commencement of antiretroviral treatment. In developing countries such as South Africa, where the largest number of people living with HIV/AIDS worldwide reside, specific government reproductive health policy and service provision for HIV-infected individuals is underdeveloped. This policy brief presents findings from a qualitative study that explored HIV-infected individuals’ reproductive intentions, decision-making, and need for reproductive health services. The study also assessed the opinions of health-service providers, policymakers, and influential figures within nongovernmental organizations who are likely to play important roles in the shaping and delivery of reproductive health services. Conducted at two health centers in the Cape Town metropolitan area in South Africa from May 2004 to January 2005, the study focused on issues that impact reproductive choice and decision-making and identified critical policy, health service, and research-related matters to be addressed

Paving the Path: Preparing for Microbicide Introduction—Report of a Qualitative Study in South Africa [Executive Summary]

With recently accelerated support for the development of microbicides to prevent HIV transmission and the urgency of the global AIDS epidemic, it is important to begin to identify strategies for introducing a microbicide once it is proven safe and effective and is approved for use. This executive summary presents results from a qualitative study that explored a range of issues likely to influence microbicide introduction at the community, health service, and policy levels. The study, which identified critical issues to be addressed in building support for microbicides and facilitating a smooth introduction, was conducted between September 2002 and September 2003 in Langa, a peri-urban site in the Western Cape Province of South Africa, and at national and provincial levels. Through in-depth interviews and focus group discussions, this study explored and identified issues that could facilitate or undermine access to and use of microbicides. Respondents included community members, health care providers and managers, provincial- and national-level government officials, and representatives from national and provincial nongovernmental organizations and health professional bodies that influence policy

Paving the Path: Preparing for Microbicide Introduction—Report of a Qualitative Study in South Africa

With recently accelerated support for the development of microbicides to prevent HIV transmission and the urgency of the global AIDS epidemic, it is important to begin to identify strategies for introducing a microbicide once it is proven safe and effective and is approved for use. This report presents results from a qualitative study that explored a range of issues likely to influence microbicide introduction—positively or negatively—at three levels: community, health service, and policy. The study, which identified critical issues to be addressed in building support for microbicides and facilitating a smooth introduction, was conducted between September 2002 and September 2003 in Langa, a peri-urban site in the Western Cape Province of South Africa, and at national and provincial levels. Through in-depth interviews and focus group discussions, this study explored and identified issues that could facilitate or undermine access to and use of microbicides. Respondents included community members, health care providers and managers, provincial- and national-level government officials, and representatives from national and provincial nongovernmental organizations and health professional bodies that influence policy