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Repro Health/HIV » Women's Courage

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A whole new meaning to 'sexting'…

February 24th, 2011

This week I came across an interesting article in the New York Times about using SMS text messages to provide teens with free, anonymous, and frank information about their sexual and reproductive health (Hoffman, 2009).  The program, called “The Birds and the Bees Text Line”, was started just two years ago by the Adolescent Pregnancy Prevention Campaign of North Carolina.  The group offers information that kids cannot get in school: in NC, abstinence only education is mandated by state law. A staff member responds to each text message individually.  9 staffers rotate these response duties.  Each have graduate training in public health or social work, or years of experience working with teenagers.

The questions, as you might expect, range from myth-busting (If you take a shower before you have sex, are you less likely to get pregnant?) to requests for help with behavior change (How can I stop myself to giving into sexual temptations?) to innocent (Why don’t girls like short guys?).  Of the examples discussing in the article and a sister article published the same day (”Text Ed”, NYT), many pointed to disturbing gaps in teens’ knowledge (“If ur partner has aids and u have sex without a condom do u get aids the first time or not?” or questions about whether anal sex can pass STIsor cause pregnancy).  The responses are short, straightforward, non-judgmental, and often caring.  For example, a texter might respond to the question above about showering before sex, “Nope, doesn’t make a difference.”  Often, the article says, the service offers referrals to local clinics or other providers where the adolescent can get more comprehensive care.

This type of program is becoming more common in our digitally-oriented world.  California has an initiative called “Hook Up 365247″ that sends weekly  text messages with sex education/information and life advice (Teen Source, 2011).  Subscribers can also receive referrals to clinics in their area.  For example, Everyone gets the same messages, which are scripted rather than responses to specific questions.  You might learn from these text messages: “Meds cure chlamydia, gonorrhea + syph. herpes + HIV stay w/u 4ever. Txt CLINIC + ur zipcode 4 clincs.”

Trolling the web, I also found an initiative called “Sex Ed Text” (SET, 2011) which offers something similar to Birds and Bees in the Phillipines, but with a  decidedly adolescent style.  Rather than answering personal questions, SET uses computer program to respond to text messages containing specific keywords, including “preg” “stds” “hivaids” “condom” “pill” and “tubestyed.”  Users then select from a number listed of frequently asked questions within each key word.  For example, texting about “pill”, one would need to specify their inquiry from this list:

1-how 2 use
2-misd pill
3-can i stil have kids
7-can I tak d pill
9-gud or bad

The questions and answers themselves are also written in this slangy, informal style, while still providing useful information.  If I texted the service with a question about how to use a condom, I would receive this repsonse:

How 2 use-condom wil only work if used proprly. Put d roled up condom over stif penis, pinch tip of condom 2 leave space 4 sperm,  roll condom down d penis. D man shud hold d condom when he puls out his penis frm partnr 2 prevent sperm frm leakin out. A condom shud only b used once.

A program recently launched in Indonesia allows teenagers and anyone with access to a mobile phone to send questions to a panel of Indonesian doctors via text message (Jakarta, 2007). The program was started by a condom manufacturer ‘Fiesta Condoms’, who report that they felt Indonesian teens lacked access to sex education information (according to a study in four major cities that many teens were getting the knowledge primarily from pornographic videos online).  Like the other programs mentioned, the service works anonymously, allowing youth to access information without fear of breaking social taboos.

What should we think of all this?

The programs clearly fill a gap,  In North Carolina, texting the Birds & Bees hotline might be the only time a teen gets information about contraception, since they won’t ever learn about it in school.  Cell phones may be more difficult for parents to regulate (compared to the internet, which allows parents to block certain sites), meaning adolescents might have more privacy than other digital sources allow.  While it certainly cannot replace comprehensive, face to face sex ed programs, it doesn’t claim to.  It’s meant to give teens a forum to ask questions, and ask they do.  On the whole, I can get behind this type of program, but I do have some qualms.

What worries me about the Birds & Bees hotline in NC and the Indonesian doctor hotline is the idiosyncraticity and brevity of the responses.  The “Hookup” program in California circumvents this issue by sending weekly tips rather than answering specific questions.  The “SET” initiative in the Philippines answers pre-determined FAQs with pre-determined responses.  But when staff answer individual, personal questions, they must think carefully about how to respond to the specific individual’s needs, provide full information, encourage the adolescent’s safety and health, all while not presenting a judgmental or patronizing tone.  These challenges are present in any human interaction around difficult to answer questions, but they intensified here by the medium of texting.  You get 140 characters, little means of communicating tone, and no information about or rapport with your audience.

Take for example, the question about whether you can avoid pregnancy by taking a shower before sex.  “Nope, doesn’t make a difference” is a non-judgmental, accurate answer.  It meets the teen where they are, doesn’t shame them for asking questions, and gives them the information they need quickly.   But are there still important gaps in this answer?   The question itself demonstrates that the teen doesn’t have good knowledge of how pregnancy works or how to avoid it – would it be useful to refer him/her to a clinic or internet resource that could educate them about pregnancy and contraception? To address other common myths about pregnancy?  To probe to see if they have other questions? You can’t necessarily assess what the teen knows (or doesn’t know) beyond their question’s content, so even after an appropriate response, important gaps might remain in the teen’s knowledge.

According to an article by momlogic.com, part of this difficulty is dealt with by not answering every question at face value. “We will refine what they’re asking, clarifying questions,” says Sally Swanson, one of the responders in the program (as quoted here: http://www.momlogic.com/2009/05/sex_educaton_text.php).  But what about questions like these (from the Hoffman, 2009 article):

“If I was raped when I was little and just had sex was it technically my first time when I was raped or when I recently had sex?”


“I like boys but I also like girls. What should I do?”

Clearly, text message programs are not equipped to respond comprehensively to issues of domestic violence & sexual abuse, sexuality and sexual identity, or morality.  In these cases, referrals are paramount.  An important question to assess might be, how often do teens seek more intensive information/care after using a text message service?  Other evaluation questions will surely be studied as well, to judge such programs effectiveness at increasing knowledge, changing attitudes, promoting safer behaviors, and accessing community services.  For now, I think it’s safe to say that while clearly not a substitute for comprehensive education, these anonymous, youth friendly programs are an important way to increasing teen’s access to knowledge about their sexual and reproductive health.  And given the prevalence of cell phones world wide, even in developing nations, using SMS as a means to communicate information could represent an important movement in public health education.

What do you think?


Hoffman, J. “When the Cell Phone Teaches Sex Education.” New York Times, May 1, 2009. Accessed online at: http://www.nytimes.com/2009/05/03/fashion/03sexed.html?_r=1&pagewanted=all

“Text Ed.” New York Times, May 1, 2009.  Accessed online at: http://www.nytimes.com/2009/05/03/fashion/03sexbox.html?ref=fashion

Teen Source: “The Hookup.”  California Family Health Council, 2011.  Accessed online at: http://www.teensource.org/pages/hookup

“SMS Sex Education Line Launched.” Jakarta Post, July 19, 2007.  Accessed online at: http://www.thejakartapost.com/news/2007/07/19/sms-sex-education-line-launched.html

“Teen Sex Ed: Just a Text Message Away.” GNH Productions, 2011.  Accessed online at: http://www.momlogic.com/2009/05/sex_educaton_text.php

Obstetric Fistula and Unacceptable Suffering

February 24th, 2011

Last week I wrote about the dangerously high prevalence of caesarean sections in developing (and developed!) countries. This week, I’m writing about a horrific condition that can result where c-sections are needed and not available. That condition is obstetric fistula. I know a lot of you watched A Walk to Beautiful, and I sincerely hope this post isn’t redundant for you. I feel that fistula is a topic that has to be talked about a lot, due to its utterly appalling and preventable nature.

Obstructed labor, which happens in 5% of live births, occurs when the baby is too big to make it through its mother’s birth canal (1). (Or when the mother is too small to accommodate her baby—unsurprisingly, obstructed labor is especially common “in parts of the world where girls grow up malnourished, marry early, and become pregnant before they have achieved full pelvic growth” (2)). It’s a problem that needs to be solved with surgery, specifically a c-section. However, as we well know, emergency obstetric services are simply not available to many women, particularly in rural areas. The result is that women may remain in labor for four or five days without intervention. That experience alone is hard for many of us to imagine, but the details—and what comes next—are far worse. Contractions cause the fetus’s head to exert pressure on its mother’s pelvis. As this pressure increases it eventually cuts off blood supply to soft tissues in the area, resulting in a horrifying one-two punch of maternal tissue damage and fetal death by asphyxiation. After a couple days, the deceased fetus changes shape sufficiently to exit its mother’s body; “a slough of necrotic tissue” follows a few days later, leaving a fistula—small hole—between the bladder and vagina, and sometimes also the fecal tract. (2)

The result is that women experience constant incontinence, leaking urine and/or feces through their vaginas. This “often leads to social isolation, skin infections, kidney disorders and even death if left untreated”(1). Even if women experience initial support and compassion from their families, ultimately as their husbands view their fistulas as incurable, they are frequently divorced and abandoned. (2) Women with fistulas are put in an unimaginably miserable position. I read the excellent book Half the Sky for my book report, and the authors told a story of a 21 year old Ethiopian woman, Simeesh, who got a fistula and was left by her husband after fellow passengers on a bus wouldn’t let her ride with them to the hospital to seek help due to her odor. Her parents supported her, building her a separate hut and bringing her food and water—although consuming it only increased the amount of waste leaking down her legs, so she slowly starved. An estimated 90% of fistula patients have considered suicide. Simeesh’s misery and depression were so severe she remained in the hut in a fetal position for two years. When she eventually got help, she wasn’t able to move her own legs. Through the incredible work of the Addis Ababa Fistula Hospital, she eventually had her fistula repaired and made a full recovery. (3)

Simeesh’s story is a powerful one because it shows how truly life-destroying fistulas are. A few pertinent facts:

  • WHO estimates that 2 million women are living with untreated fistulas in Africa and Asia. (2)
  • 50,000 to 100,000 women develop obstetric fistula annually. (2)
  • “The basic techniques needed for fistula repair have been known for more than 150 years” (1)
  • The average fistula patient is under 25 years old. (1)
  • Reconstructive surgery is successful in 88–93% of first-time cases and costs about US$350. (4)

So what can be done to address this shamefully preventable problem? To begin with, fistula is the result of many of the problems we’ve studied in this class: “Fistula sufferers tend to be young, illiterate, destitute women from rural areas, without political influence or economic resources”(2). More attention must be paid to these underlying factors. In terms of fistula itself, first comes preventing prolonged obstructed labor. Younger women and teenagers are more at risk for obstructed births because of their smaller frames. Thus, a crucial way to prevent fistula is to promote later marriage and childbirth, and of course the best way to do that is through education (4). At a more proximal level of prevention, improving women’s access to emergency obstetric services—specifically, c-sections—remains absolutely critical (4). Beyond that, there is of course severe need to treat the population of women living with fistulas—many of them either unaware their crippling condition is completely treatable, or unable to access care (4). A major problem is that women with fistulas are simply not the priority: within the international aid community and within local hospitals. Dr. Lewis Wall, president of the Worldwide Fistula Fund, writes, “[patients with fistula] are at the bottom of the heap socially, sexually, economically, politically, and medically” (2). For this reason, clinics that are specifically devoted to treating women with fistulas are desperately needed. Addis Ababa Fistula Hospital, mentioned above, is a wonderfully successful example that’s treated some 25,000 patients (2). Of course, specialized hospitals may be sparse and difficult to reach for women “at the bottom of the heap.” Thus, awareness campaigns for communities are needed, so that families and husbands shift from stigmatizing a patient to helping her get the treatment that will cure her. There is also urgent need to raise international awareness of fistulae, the immense suffering they cause, and their utterly preventable and treatable nature. The stories of the unnecessary atrocities women face as a result of childbirth must be shared so that we can all develop a bit more shame and outrage and put an end to this suffering.

A woman recovering from obstetric fistula at Addis Ababa Fistula Hospital

  1. http://www.who.int/features/factfiles/obstetric_fistula/en/
  2. http://www.fistulacare.org/pages/pdf/Partners/Virtual-Resource-Center/JournalNews/Overview/Wall.pdf
  3. Kristof, Nicholas D., and Sheryl WuDunn. Half the Sky: Turning Oppression into Opportunity for Women Worldwide. New York: Vintage, 2010.
  4. http://www.fistulafoundation.org/pdf/lancet%202004.pdf

A Sisterhood of Support

February 24th, 2011

After exploring the horrifying causes and consequences of the sex trade in Cambodia, I think it is time to cover a more positive aspect on the issue: the courage of survivors, the importance of support during recovery, and the road to healing. I’ve chosen to explore some successful programs in Cambodia which aim to empower women through various approaches. As Anne highlights in her book, there are many women’s groups who have come together to support each other and advocate for change. I believe that we can learn from these groups’ approaches and experiences how to best support women and girls who have been rescued or have escaped from the sex trade. As emphasized by Betsi Hoody and Devi Leiper of the Global Fund for Women, it’s “rights not rescue” that we must remember to focus on. With issues of human rights violations, I’ve found that is so important to look at both prevention, education, and awareness and ways to rehabilitate the survivors of abuse and help them integrate back into society, in culturally sensitive and healthy ways.

Devi Leiper explained that many women in Cambodia want factory jobs and economic independence. They move to urban centers hoping to find employment that will allow them to provide for their family, gain social status, and feel empowered by her efforts. With the migration of poor women into the cities, we see many getting coerced into trafficking schemes – taken to other parts of Asia for domestic work, and tricked into sex work domestically or abroad. Women are easily trafficked because their labor (not to mention their worth as human beings) is undervalued and often goes undocumented. So what happens when women see their only opportunity for income or economic independence in sex work? In the words of Somaly Mam, many girls and women “have no choice. They have to sell themselves, they have to have sex.” What if they are lured by promises of a good job, but get taken to a brothel and become indebted to the owner?

What about the girls and women to escape the brothels, or are rescued by NGOs or sudden police raids? Where do they live once they are “free?” How do they reintegrate into society, join the workforce, regain the trust and love of their family? How can we help survivors of abuse find support, love, and acceptance in a supportive community of fellow survivors? I believe we can begin to tackle these challenging questions by learning from the missions and actions of these organizations:

1. Kachin Women Association Thailand (KWAT)

  • Fact: Young women are vulnerable to forced sex because of the violent conflicts in Thailand, Burma, Cambodia.
  • Goal: Train young women to become leaders of the women’s rights movement and work to cultivate gender equality in the community.
  • Approach: Promotes women’s rights and tries to restore their status in post-war society through leadership and skills training “to help women become politically aware and economically independent” (Murray 155).

2. Girl Guides Association of Cambodia

  • Fact: Today’s girls are tomorrow’s women. If we empower young females, we can cultivate gender equality and increase understanding of women’s unique health issues.
  • Goal: Educate young girls to become “the agents of change” by teaching them about domestic violence, gender equity, women’s health issues.
  • Approach: Offer non-formal education and encourage participation in community projects and camping trips to help the girls “develop self-esteem, appreciation for leadership, and concrete roles as responsible members of society” (Murray 68).

3. Urban Poor Women Development, Phnom Penh (UPWD)

  • Fact: Poor women in poor urban areas generally have low social status and limited economic opportunities.
  • Goal: Help poor women in urban areas find jobs and develop economic independence and increased social status.
  • Approach: Give funds to women to start small businesses, train women to be leaders in local organizations and NGOs (Murray 5).

4. Strey Khmer in Cambodia

  • Fact: Cambodia’s political system is dominated by men. Women’s voices and rights need to be heard and respected.
  • Goal: Encourage women to get involved in politics, so that at least 30% of government seats will be filled by female leaders in the near future.
  • Approach: Lead workshops in language training and leadership skills, teach classes on gender-based violence and women’s health, include male supporters of women’s rights in the effort (Murray 223).

As I discussed in my first blog post, I am most moved and inspired by the mission and work of the Somaly Mam Foundation. Founded by Somaly Mam, an escaped Cambodian sex slave, the foundation works with AFESIP to fund shelters in Cambodia, Vietnam, Laos, and Thailand that house rescued girls and offer them “the comprehensive services they need to heal, and to create healthy, sustainable futures for themselves.”

Somaly is more than a survivor, she’s a human rights crusader, saving girls from brothels and giving them a new life. “The Road to Traffik” movie explains that “Somaly was once told by a man that if she wanted to survive, she had to keep her silence. But she is no longer keeping silent. She is giving a voice to these girls.” Somaly’s work is a living testament that “raw courage can transcend a world of cruelty.” Her organization is unique because it employs doctors, social workers, and former victims to teach the girls and women at her centers about AIDS prevention, sexual health, emotional health, women’s rights, and the joys of living freely and independently. “Being a former victim myself, I know exactly what their needs are. What they need most is love and understanding,” she explains.

  • Goal: Provide girls and women with the skills to reintegrate into society and the courage and self-esteem to reduce their risk of falling back into the sex trade.
  • Approach: “All of our programs share an emphasis on the collective voice of the survivors, who participate in every aspect of our work. Survivors who have gone through our rescue, rehabilitation, and reintegration programs can choose to join our Voices for Change initiative, which offers them the opportunity”  to do outreach and teach classes to other survivors. VFC members visit brothels, distributing condoms and doing HIV/AIDS education.

The women who have started these organizations are strong, loving, courageous, creative, and determined. The women they serve are survivors, healers, mentors, teachers, mothers, sisters, lovers, and friends. The power of women to envision and actualize change cannot be underestimated. In the words of Maya Angelou, “You can write me down in history with hateful, twisted lies, you can tread me in this very dirt, but still, like dust, I’ll rise.”


Murray, Anne. “From Outrage to Courage.”

Roy, Norman Jean. “The Road to Traffik.” <Somalymamfoundation.org>

Postpartum Family Planning

February 24th, 2011

In past weeks of this blog I have covered a number of interventions that attempt to address the major causes of maternal mortality during the intrapartum period. No discussion of maternal mortality would be complete, however, without addressing family planning.  In researching family planning programs I stumbled across the statistic that rates of contraception use in the year following the birth of a child are significantly higher among women who receive family planning education within 6 months of giving birth as compared to women who receive this information later.[i] This statistic got me to thinking about ways we might use the system put in place for safely delivering babies in order to offer access to family planning information and birth control. For many women, labor and delivery represents a unique point of contact with the medical system. During this time, many women are highly motivated to use contraception in order to space or limit their pregnancies. Medical and peri-medical staff involved in the delivery process need to be prepared to meet this demand.

Despite apparent opportunity to offer family planning services during the intrapartum period, research in this arena appears to be relatively limited. In the words of one researcher, “We know more about contraceptive methods appropriate for postpartum women than we do about what works to help postpartum women choose a contraceptive.[ii]” Despite getting less attention than issues such as postpartum hemorrhage, postpartum family planning has sparked a couple of particularly interesting studies. One such research project was brought up in my Global Public Health class the other day by Dr. Paul Blumenthal. In a nutshell, this project looks at the feasibility and effectiveness of offering postpartum IUDs. The logic behind this program is that (1) new mothers are particularly likely to want birth control, (2) copper IUDs are very inexpensive and last a long time, and (3) inserting and IUD is considerably easier following delivery, because the cervix is already dilated. A recent study in Zambia found that many women were accepting of postpartum IUDs (PPIUDs), with approximately 1,500 PPIUDs inserted during the course of the one year study (representing 9% of IUD use in Zambia).

Postpartum IUD insertion sounds like a promising idea, but it is feasible outside the hospital setting? As highlighted in earlier weeks of this blog, many women around the world continue to give birth at home. Giving birth at home introduces several obstacles to providing postpartum IUDs. First, many women who give birth at home do not receive antenatal care. Without antenatal visits, birth attendants have little opportunity to discuss IUD insertion with the woman before delivery. Secondly, while IUDs are easier to insert postpartum, the procedure still carries some risks and requires some tools. This means that midwives would need to be specially trained in order to safely perform the procedure. While some programs have attempted to teach midwives to perform this procedure outside hospitals, successful program have been limited primarily to the clinical setting.[iii]

While PPIUDs are likely not a good option for the home-birth setting, many other good options for postpartum contraception exist. Given this, I wondered if other forms of postpartum family planning education might be beneficial to women giving birth outside of a hospital or clinic. The answer, unfortunately, appears to be that such postpartum contraception education often has little impact. Since many woman who have home-births do not receive prenatal care, family planning counseling by community midwives is limited to a single postpartum conversation. A survey by Ovid assessing the efficacy of many different postpartum family planning programs found that such conversations are unlikely to influence a woman’s contraceptive use.[iv] According to this study, more intensive interventions, involving multiple repeat visits are necessary in order to significantly influence family planning outcomes.[v] Even with these more involved interventions, actual increases in contraceptive use can only be achieved if the contraceptive methods are routinely available. The results of these studies on postpartum family planning appear to suggest that considerable additional resources are necessary in order to make postpartum family planning work outside the clinical setting.

[i] Vernon, Ricardo. “Meeting the family Planning Needs of Postpartum Women.” Studies in Family Planning.Vol 40. Issue 3. 28 August 2009. pp 235-245.

[ii] Lopez et al. “ Postpartum Education for Contraception: A systematic review.” Obstetrical and Gynecological Survey. Vol 65. Issue 5. May 2010. Pp 325-331.

[iii] Ibid

[iv] Ibid

[v] Ibid

U.S. Latino Sex and Birth Control: Research and Room for Improvement

February 24th, 2011

I now hope to look at the research that has been done on Latinos in the U.S.  regarding sexuality and birth control. According to the National Campaign to Prevent Teen and Unplanned Pregnancy (National Campaign), among all races/ethnicities in the U.S., Latinas have the highest teen birth and pregnancy rate. Before turning 20, 52% of Latinas get pregnant. Much of this, the National Campaign has claimed quite accurately, is due to the fact that Latino teens in the U.S. are also less likely than their non-Latino counterparts to use contraception. See Graph 1, below, for an especially interesting graph from the 2008 National Campaign’s Latino Initiative which compares condom usage between U.S. Latino teenagers and all U.S. teenagers.

Graph 1: Sexually active teens, reporting if condom was used during last intercourse

An Interesting and Important Field of Research

Before discussing research, I would like to first stress a key aspect within the context of this research on sexuality and birth control: Latinos living in the United States continue to be affected by the HIV/AIDS epidemic to a greater extent than non-Hispanic whites. Furthermore, Latino teens have been disproportionately impacted by the disease. In 2005 for those aged 25 to 44, HIV was the 5th leading causes of death for Latina women. And among those in this age bracket, death from HIV was more likely for Latinos than whites—and their HIV incidence is around 4 times higher than the rate for their white counterparts (Kaiser). Yet, when looking at all of these statistics, I think an incredibly important facet is being neglected. It is important to remember that “the impact varies across the country and by place of birth” (Kaiser). I’ll expand more on this variation issue later in the post.

One of the largest recent studies done on the issue of Latino sexuality and birth control was conducted in 2008 when 694 Latino adolescents (nearly half-and-half, with slightly more females) aged 16–22 living in the United States were interviewed on condom negotiating strategies. “Almost 60% of participants reported wanting to use condoms, and nearly all of these used some strategy to obtain condom use.” Interestingly, the young men who wanted to use condoms were more likely to use a negotiating strategy compared with their female counterparts who also wanted to use condoms (Tschann).

The study concluded that providing ones partner risk information through direct verbal/nonverbal communication “were effective strategies to obtain condom use, even among youth who perceived their sexual partners as not wanting to use condoms.” In the 40% of participants who reported not wanting to use condoms, “ignoring condom use was an effective condom avoidance strategy, even when youth thought their partners wanted to use condoms.” The most unexpected outcome, however, was that young Latino men “who expressed dislike of condoms had higher rates of condom use than young men not using this condom avoidance strategy” (Tschann). This study has limited application to sex-ed classes in the United States for Latino adolescents, but mostly provides us a baseline of understanding what sort of studies have been occurring around condom usage in the U.S. Latino population.

In this context, I became interested in another study done in the late 1990s compared high-risk sexual behaviors and reproductive health among Bay Area women in their late teens and early 20s. The study found some interesting comparisons between the defined groups of “foreign-born Latinas, US-born Latinas, and US-born non-Latinas” (Minnis). US-born Latinas were more likely than the other two groups (foreign-born Latinas and US non-Latinas) to have had an abortion, and also were most likely to be infection with chlamydia (Minnis). Among teenagers, the trend seemed to continue: Latinas born in the United States were more likely to have been pregnant. Yet, in an interesting turn, Latinas born elsewhere were by their early 20s more likely to have been pregnant compared to US-born Latinas and US-born non-Latinas (Minnis).

Addressing the Issue of Variation

But what do results from these studies, as interesting as they are, really mean? Given that “Latino” contains at least 20 different groups, in a wide range of socio-economic statuses, it seems obvious to me that surveys should start being more specific.  According to University of Illinois Marcela Raffaelli, a professor of human and community development who works on Latino teen sexuality, such statistics disguise how complicated of a group “Latinos” encompass (PharmD).

The issues arise on an ethnic basis as well the time periods when people immigrated; for example:

“Cuban immigrants who moved to the United States when Castro came to power tended to be very wealthy, and they created an entrepreneurial, successful enclave in Miami. Compare them with Central American immigrants who may be refugees from a civil war in the 1980s. Language, religion, and some aspects of culture are apt to be the same, but socioeconomic status is probably very different, and that’s a big predictor of early sexual activity and teen pregnancy” (PharmD).

So when it comes down to it, adjusting for “socioeconomic status and other demographic factors,” is all that needs to be done to remove any differences in sexual behavior between American-Latino adolescents and other American groups (PharmD).

Another important factor to consider is cultural factors and how those are represented in US studies of Latino sexuality. Researchers need to focus more on cultural factors as influences sexuality in a broader conception. According to Raffaelli, “People talk a lot about Latino culture and sexuality, but they typically don’t measure cultural variables, such as adherence to cultural norms and attitudes, in their studies” (PharmD). Without this accurate research, we cannot know to what degree ideas of machismo and marianismo—that is, idealizing the Virgin Mary—influence American-Latino youth. Furthermore, these ideas translate into different things when people cross borders. For example, Raffaelli explains that “in traditional Latin cultures, machismo dictates that men be virile and strong and provide for their family. In the United States, when we say macho, often we mean someone’s a male chauvinist, but in most Latin cultures, this idea encompasses such positive behavior as being responsible for your family and taking care of your household” (PharmD).

In the realm of teens’ sexual risk taking, Raffaelli argues that “recent immigration seems to be a protective factor. Families tend to bring the practices they had in their home country, and over time there’s a shift as they become acculturated” (PharmD).  For girls, the typically more conservative countries in sexuality lead to first-generation girls to be less risky in sexually behavior on average. On the other end, boys, may be more sexually risky “because in many Latin American countries men have more freedom to explore their sexuality” (PharmD). In this context arises the scholarly theory of the “immigrant paradox,” where immigrants even in more challenging situations can have better youth outcomes than children born in the US: “First-generation teens do better in school, get into less trouble, have fewer early pregnancies, and so on, but by the second or third generation, that protective effect dissipates. A lot of immigrant families have tremendous optimism. They think, our life here is difficult, but we’re here to improve our children’s chances and, besides, things may be worse back home,” states Raffaelli (PharmD).

Graph 2: Number of Latinos Estimated to be Living with AIDS in 2006: Top Ten Area

Aside from these issues of sexuality and condom use varying between ethnicities and socio-economic statuses of Latinos living in the U.S., another interesting factor is geography within the United States. Latino experiences of the HIV epidemic is heterogeneously distributed—cases are highest in the eastern region of the United States, especially the Northeast. Indeed, “AIDS prevalence among Latinos is clustered in a handful of states, with 10 states accounting for 88% of Latinos estimated to be living with AIDS in 2006. New York, California, and Puerto Rico top the list” (See Graph 2 to left). To return to the earlier theme, of all AIDS-infected Latinos in the U.S. in 2006, one third were those born in the U.S., followed by Latinos born outside–17% for both those born in Puerto Rico and those born in Mexico (Kaiser).

In conclusion, I hope that researchers continue to do important work in this area. However, a first step in the acceptance of “Latino” as a very wide categorization. While the issues of birth control and reduction of unwanted pregnancies and STIs (especially, but not limited to HIV/AIDS) need to be urgently addressed in this population (as with many others), a key step in that progress is acknowledging the variation. Success will be difficult without an increased sense of cultural sensitivity–and more important in many ways, a recognition of pure statistical variation–between the wildly different ethnicities, regions, and birthplaces of Latinos living in the U.S.


Works Cited

Minnis, Alexandra M. and Nancy S. Padian. “Reproductive Health Differences Among Latin American- and US-Born Young Women.” Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 78,No. 4,December 2001. The New York Academy of Medicine. <http://www.springerlink.com/content/w0r494056777q26u/>

National Campaign to Prevent Teen and Unplanned Pregnancy. “An Overview of Latina Teen Pregnancy & Birth Rates,”<http://www.thenationalcampaign.org/espanol/PDF/latino_overview.pdf>and the Latino Initiative graph from 2008 presentation.

PharmD, Doctor. “Are Latino teens sexual risk takers? It’s complicated, researcher says.” April 14, 2010. International Adoption Articles Directory. <http://www.adoptionarticlesdirectory.com/Article/Are-Latino-teens-sexual-risk-takers–It-s-complicated–researcher-says/89105>

Tschann, Jeanne M, PhD; Elena Flores, Ph.D.; Cynthia L. de Groat, M.A.; Julianna Deardorff, Ph.D.; and Charles J. Wibbelsman, M.D. “Condom Negotiation Strategies and Actual Condom Use Among Latino Youth.” Journal of Adolescent Health. September 2010, Vol. 47; No. 3: P. 254-262.

Why a Doula?

February 18th, 2011

In my blog post from last week I mentioned that the Homeless Prenatal Care program in San Francisco offers Doula services. I realize now that I forgot to clarify what a Doula is and how they may be helpful in improving women’s health and well-being in childbirth!

A doula is a childbirth assistant who provides emotional and physical support for mothers-to-be. Usually a doula works with a woman who is giving birth in a hospital setting. She is trained in ways of making labor more comfortable with birthing positions, exercises and massage techniques, and facilitates communication between laboring women, their partners, and their care providers.

This sounds like a very exclusive privilege, to have someone accompany you to an impeccably outfitted, safe, American hospital so that you can give birth comfortably and have your acupressure points massaged as you undergo contractions. (Meanwhile thousands of women around the world are giving birth in unassisted, unhygienic conditions, many of them in grave danger of fistulas, hemorrhage, and death.) Nevertheless, if I have learned anything through my exploration of birth in the US in this blog, it’s that while our medical infrastructure and technology is sound, there are still things that need a lot of work in order to ensure the safest possible birth experiences.

As I have mentioned before, one of my biggest concerns is America’s incredibly high rate of C-sections: 32%. Let me remind you that this is a rate twice as high as that recommended by the WHO, and that the risk of death following C-sections is more than three times as high as for vaginal births. So when I learned that in a 2004 study of 1,000 women, those who gave birth with Continuous Labor Support were 26% less likely to have a cesarean section, I was very excited about the potential of the labor support movement. Women were also 41% less likely to give birth with vacuum extraction or forceps and 28% less likely to use any pain medications. Best of all, they were 33% less likely to be dissatisfied with their birth experience!

But then I thought, “of course, anyone who would choose to have a doula is probably less likely to have a caesarian!” Looking more closely at the studies (by ED Hodnett and Colleagues), I found that these are not just observational studies of those who chose labor support– the researchers use randomized controlled trials, where participants are randomly designated to receive or not receive labor support. I also found that “Continuous Labor Support” denoted not only doulas but family or friends, trained or untrained, who attended the birth and provided active support to the laboring mother. It seems obvious: having a trusted person or loved one present who can support us emotionally in difficult times and provide us with physical comforts is a plain ole’ good thing!

Nevertheless, trained Doula care can be particularly useful in many cases. For example, in communities where women are systematically mistreated in the medical system and often coerced into undergoing procedures they haven’t asked for, a doula can be incredibly helpful in supporting well-reasoned decision making. A doula has learned about the procedures and drugs that can be used in childbirth, and can clarify medical jargon so that a woman can better understand what kind of choices she is being asked to make. A doula can be vocal on a woman’s behalf if the woman isn’t in a state to assert herself. And a doula can make all the difference in a woman’s attitude towards birth, shifting it from a fear-driven approach to a more natural, celebratory one. And that is something incredibly empowering. I am glad more and more women are having access to this through community volunteer doula programs.

Check out the links below for more info! For more statistics on birth in America, see my first blog: http://stanford.edu/class/humbio129/cgi-bin/blogs/blog/2011/01/13/667/ The studies by Hodnett et. al.: http://childbirthconnection.org/article.asp?ck=10128 The most popular International Doula Certification program, DONA: www.dona.org Cool volunteer doula programs: http://www.bayareabirth.org/probono/ http://health.ucsd.edu/women/child/doula/ http://sfghdoulas.org/doulaprogram.html

From Russia with love: lack of evidence-based guidelines and possible impact on maternal health

February 18th, 2011

After the war, the Soviet Union had seen a marked improvement in reproductive, including maternal and infant, health outcomes. However, by the 1980s it did not match the statistics of Western European countries (WHO 2004). Researchers suggest that these improvements in reproductive health were a result of an “extensive network” of maternity facilities, under highly centralized control,” which enabled almost universal access to basic care ( Danishevski 2006). The Ministry of Health developed the prikaz, a system of decrees or orders, which mostly dealt with the structure of local health systems and the interventions given, including norms for staffing and facility operational procedures. For antenatal visits and blood tests, for instance, it delineated the frequency of visits and procedures during the visits.  Prikaz was based on medical textbooks written by an elite group of senior specialists which, researchers argue, did not reflect the reality of clinical practice (Danishevski 2006).  A discrepancy existed between what the government provided (mostly what it didn’t) and what the literature recommended.

After the Soviet break up, Russian regional administrations funded and delivered health care while still trying to comply with the Ministry of Health’s recommendations. Some regions have tried to include evidence-based  health care principles which had been previously rejected by the traditional Russian scientific paradigm, but which are still not fully included in the ministry of health guidelines. For example, a standard text used by obstetricians and midwives,  the  “Guide to effective care in pregnancy and childbirth,” which draws information from  medical literature and the Cochrane library, has been translated to Russian but is not accessible to Russian practitioners or welcomed by others.

There is also still an increase in variation between what is provided and the ministry-approved guidelines. Regional health centers in some regions are also reluctant to accept international guidelines, and some requirements the Russian Health Ministry have legislated to standardize some clinical practices aren’t often aligned with international evidence-based guidelines.

For example, a study by the London School of Hygiene and Tropical Medicine, the University of Edinburg and the University of Wiwatersrand in Johannesburg found that maternity units in the region of study do not follow international, evidence-based practice guidelines (Penn-Kekana), In some health centers all expectant mothers were hospitalized for “poorly defined” conditions like “prevention of miscarriage.” Some women were hospitalized for this condition for about 28 days. This raises the question of whether those beds should be better used or if it is a reflection of the low birth and high abortion rates in Russia. Other  practices not following evidence-based guidelines included:  routine enema and shaving, recumbent bed position in labour and routine fetal monitoring.  Routine obstetric practices also raised warning signs since they included prescription of multivitamins and strict dietary restrictions of red fruit and vegetables(Penn-Kekana).

Danishevski et al. contend that there is stark contrast between the “official situation” in which clinical practice is highly regulated through guidelines, and the reality which encompasses a variation among facilities, with neither option significantly relying on evidence of effectiveness. Many of the decisions are in practice left to the discretion of individual physicians.  Although it is difficult to relate the patterns of intervention in individual facilities to obstetric outcomes, the aforementioned findings shed light to possible contributors to the poor rates of perinatal and maternal mortality in Russia.


Danishevski, K. “Delivering babies in a time of transition in Tula, Russia.” Health policy and planning 21.3 (2006):195.

Penn-Kekana, L. “Improving maternal health: getting what works to happen.” Reproductive health matters 15.30 (2007):28.

WHO. 2004. Health for all database. Copenhagen: World Health Organization.

An Epidemic of C-Sections

February 17th, 2011

As I was perusing for topics to write about this week, I came across Amelia’s comment on my very first blog post, where she suggested I write about c-sections in the US. I started doing some research and found to my surprise that C-section rates are dangerously high not only in the US but in some developing countries. Surveys by WHO found that in Asia, 27% of births surveyed were c-sections, and in Latin America, 35%. In the US, the percentage is 30. In China, it’s 46. (1) For a bit of perspective, WHO has recommended rates not rise above 15%, and other doctors say even above 5% is generally not justified (2). What are the factors behind these astonishingly high rates? Beyond that, what do they mean for the health of mothers and babies everywhere?

First, another note to frame the issue: I’ve spent a lot of time writing about issues of access to care and how that affects maternal mortality in developing countries. As we all well know by know, a lack of access to obstetric care, emergency or otherwise, is a major factor in the unacceptably high maternal mortality rates that continue in much of the developing world. Thus, it’s critical to note that an even worse statistic than too many c-sections is too few. Rates lower than 1, or even 3 percent “indicate a lack of access to obstetrical care and a risk of maternal death” (2).  Thus it’s unsurprising that rates of c-section remain below 1% in rural areas in Chad, Niger, Mali, Madagascar, Zambia, Haiti, and Nepal.

On the other hand, what is the outcome of too many c-sections? An ecological study of 8 Latin American countries found “overall and elective caesarean section rates to be positively associated with severe maternal morbidity and possibly mortality, as well as with fetal mortality and newborn morbidity,” after accounting for the fact that hospitals attracting higher risk pregnancies would also have higher rates of c-section (3). Given the risks to themselves and their babies, why are so many women choosing c-sections? There is a wide range of reasons, both medical and cultural. Doctors may encourage c-sections in their patients because the procedure is quicker than a vaginal birth (3). Women may choose a c-section because it’s seen as being less violent on their bodies than vaginal birth—a “harmless, painless, and convenient” process (3). There is also the misconception that c-sections are less risky than natural birth. Beyond that, it’s simply convenient to be able to schedule your birth. Yet another WHO study found that some Asian women will plan a surgery so that she can give birth to their child at a time or day a fortuneteller has told her is lucky (1).

In Brazil, a country with c-section rates approximately as high as China’s, socioeconomic factors also play a huge role in women’s choice to have a caesarean. Wealthy women are more likely to have the procedure—in fact, 55% of women with a family yearly income greater than $1000 do—so it is viewed as superior and desired medical care. Beyond that, low SES women are concerned about receiving biased or sub-par care from doctors in a vaginal birth and see a c-section as the solution. What’s interesting is that it’s all about the women’s perspectives of their treatment: the researchers write, “According to some women, a traumatic vaginal birth often occurred because of medical negligence based on social and economic prejudice…Indeed, many of the factors influencing maternal behaviors, such as fear of pain, are meaningful precisely because they are understood to differ by socioeconomic status and to be embedded in discriminating practices.” In this context, the desire to have a c-section is a function of women’s desire to establish some power over their bodies and medical experience. Unfortunately, it’s also reflective of misinformation about the benefit of caesarean sections. (4)

Interestingly, the high and increasing rates of c-sections worldwide are indicative of an over-medicalization of the birth process in developing countries. This statement may seem wrong or ironic given that so many women die because of lack of medical care before, after, or childbirth. However, studies have shown that in developing countries where medical care is available, there is an overuse of obstetrical interventions, notably c-sections but also episiotomies and oxytocin, a chemical used to augment and induce labor. All these practices are life-saving when needed, but may be harmful when used unnecessarily. (2)

Ultimately, distribution of c-sections worldwide indicates the health inequities which plague our world and especially its mothers. In The Lancet, a couple of Brazilian doctors commented on the trends in their country, noting “Within middle-income countries, inequities affect both extremes of the social scale: the rich have too many caesarean sections, whereas the poor have fewer than needed” (3). Indeed, this is the situation worldwide. In developing countries, where resources are painfully limited, prioritizing access, efficiency, and quality in maternal health care is absolutely crucial.

  1. http://www.msnbc.msn.com/id/34826186/ns/health-pregnancy/
  2. http://www.jsieurope.org/safem/collect/safem/pdf/s2938e/s2938e.pdf
  3. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68780-1/fulltext
  4. http://www.bmj.com/content/324/7343/942.full

Special Needs of Married Adolescents

February 17th, 2011

I suspect I speak for most Americans when I say that we consider marriage a low-risk environment in terms of sexual health.  This may well be true for much of the developed world.  But in many countries, marriage is not a fortress against sexual and reproductive problems like HIV/AIDS, STIs, or reproductive tract infections.  This is particularly true for young girls.

Why do married adolescents need special attention with regard to sexual/reproductive health information?

In developing countries, the most common route for risky sex for adolescent girls is marriage (McIntyre, 2006).  That’s right. No pre-marital sex, not sexual experimentation — getting married.  And A LOT of girls are married, as we saw during weeks 4 and 5 of the course (see also Haberland et al. 2003). A study in Kenya and Zambia is illustrative. The research found that young married girls were more likely to be infected with HIV than unmarried but sexually active adolescents because married adolescents have sex more often, use condoms less often, are unable to refuse sex, and have partners who are more likely to be HIV-positive (UNFPA).

These findings are found across the globe. Married adolescents are more likely than their sexually active but unmarried peers to have unprotected sex. They have more frequent sex, and condom use is rare and often highly taboo (Bruce & Clark, 2003).  In many countries, the majority of sexually active adolescents are married.  For example, in the Dominican Republic, of 15-19 year olds who are sexually active, 87% are sexually active.  Only 1.5% of these youth report condom use (Goldberg, 2003).   McIntyre also reports that married girls tend to have higher rates of HIV than their sexually active, unmarried counterparts (2006).  But despite these statistics, sex within marriage is considered safe.  A man who, before marriage, would have been considered sexually risky becomes safe when he assumes the title “husband.”  Most adolescent wives are monogamous, but it is difficult for them to know their husband’s HIV status or ensure his fidelity.

Several explanations are offered for this heightened risk.   Adolescent girls usually marry much older, and thus more sexually experienced, men (McIntyre, 2006).  (There is also evidence that the longer a girl delays marriage, the smaller the age gap between she and her husband – so the youngest brides are particularly at risk).  As we have seen in the course, while a girl’s virginity is paramount in many communities, sexual purity is rarely expected of men, and often the opposite (sexual experimentation or promiscuity) are encouraged.  When adolescent girls marry older men, they are therefore often exposed to HIV and other STIs, despite their own monogamy.  A husband may also put his young wife at risk via extra-marital sex.  Men are much more likely to have sex outside of marriage than their wives.  Indeed, they too have higher HIV prevalence than their unmarried peers.   In short, even though most married adolescents are monogamous, it is difficult for them to know their husband’s HIV/STI status or ensure his fidelity.

Young brides are also less likely to have a voice in family planning and sexual health decisions.  The older the wife, the more empowered she is to have authority over her body and reproduction (though of course there are limits to this authority due to women’s lack of social status).  Finally, in countries were girls marry young, there tends to be much social pressure for an adolescent bride to have a child soon after marriage.  Wives are expected to prove their fertility and my fear losing their husband or incurring violence from him and/or his family if she does not bear a child quickly.  This decreases contraceptive use and may counter perceived benefits of delaying childbearing (which would often be healthier for the woman, considering the risks to mother and baby of teenage pregnancy and childbirth).

Adolescent wives are rarely in school, meaning family life and sexual health information rarely reaches them, as it is usually given in secondary school (UNFPA, 2009).  They are also typically overlooked by family planning efforts (Alauddin & MacLaren, 1999), perhaps because they are perceived as being at lower risk than unmarried adolescents. McIntyre (2006) puts it clearly: “Most programmes for adoelscents do not reach married women while most services for married women do not reach adolescents.” Sexual health programs for adolescents tend to focus on lowering risk of, e.g., HIV infection by abstaining from sex, reducing frequency of sex, having sex only with a safe partner, and using a condom – but these are simply not realistic options for girls in a marriage, who have little power to refuse sex or  negotiate condom use, and cannot control their partner’s risk behavior or change to a safer partner.

When appropriate services are available, young wives are also less likely to access health and family planning services than older married women.  Compared to older women, adolescent wives have less mobility and empowerment/autonomy and face greater stigma from doctors and other health care providers (Alauddin & MacLaren, 1999).  Norms promoting fertility soon after marriage prevent women from seeking contraception.  Health systems lack female providers, and adolescents are less likely to seek these services from a male (Alauddin & MacLaren).  Younger brides are also more likely to have husbands and/or mothers-in-law who act as gatekeepers to their access to sexual and reproductive health and information.  Programs rarely reach out to these parties, who may have ultimate control over the wives’ health.

So what can be done?

Several possibilities stick out to me when I consider improving the sexual and reproductive knowledge and health of adolescent wives.  These include:

  • Education and information given to newlyweds or those soon to be married.  Consider mandatory pre-marriage counseling or family planning education before the government will grant a marriage license.
  • Home visits: We could also emulate programs  in China and Bangladesh that employ family planning field workers to bring congratulatory letters to newlyweds and motivate them to use contraception during home visits (Alauddin, 1999).  Programs in China where health care workers brought condoms to the homes of newlyweds were shown to be more effective than those that only told couples where to obtain contraceptives (Alauddin & MacLaren, 1999).
  • Health workers could also reach newlyweds through marriage registries.  For example, marriage registry employees could receive training in family planning, which they could then relay to couples when they came to apply for a marriage license.  These employees could also give couples written or picture information to take home with them.
  • Programs could raise awareness among those who often control adolescent wives’ reproductive and sexual health decisions and education (such as husbands, mothers, and mothers-in-law).  The health and economic benefits of contraceptives, monogamy, delaying childbirth, decreased fertility, etc, could be emphasized in an effort to change social norms around these issues.  Local/village leaders could be important agents of change here.
  • Married adolescents could act as peer educators, teaching their peers about sexual and reproductive health and encouraging safer sex behaviors, even within the context of a marriage.
  • Mass media campaigns can reach the general public, including married adolescents.  Special messaging could target this often overlooked age group, seeking to change norms, provide education, and promote positive role models.
  • Of course, delaying marriage is perhaps the best long-term solution, so that there are fewer adolescent wives.

I’m interested to hear your thoughts on this issue, as well as other ideas for interventions.


McIntyre, Peter (2006). Adolescent marriage: No place of safety.  World Health Organization, Geneva, Switzerland: pp. 1-40.

Haberland et al. 2003. Married Adolescents: An Overview.  WHO/UNFPA/Population Council Technical Consultation on Married Adolescents, Geneva.

Bruce J & Clark S. (2003). Including married adolescents in adolescent reproductive health and HIV/AIDS policy. WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.

Goldberg R. (2003). Early marriage and HIV in the Dominican Republic. WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.

UNFPA. (2009).  Fact Sheet: Young people and times of change. United Nations Population Fund.  Accessed from http://www.unfpa.org/public/site/global/lang/en/young_people#child_marriage

Alauddin & MacLaren (1999).  Reaching newlywed and married adolescents.  Family Health Institute.  Accessed from http://www.fhi.org/en/Youth/YouthNet/Publications/FOCUS/InFOCUS/newlywedandmarried.htm

Alauddin, M (1999). Newly married couples in Bangladesh: Pathfinder experience in adolescent reproductive health interventions. Dhaka: Pathfinder International, Bangladesh.

An Issue of Education, Not Access

February 17th, 2011

“One woman wanted to remove the IUD because her teeth had fallen out since she had it inserted. Another wanted to have it removed because she heard that the IUD would make her lose weight. Another told me it made them fat.” -Sawsan Nahawi, a general practitioner for the Jordan Association for Family Planning and Protection

Government-funded midwives at a reproductive health training

Jordan offers some of the best health care in the Middle East. Currently 86% of citizens are covered by some form of health insurance, and the government hopes to achieve 100% coverage by 2012.[1] Recently though, Jordan’s resources have been stretched thin due to the number of Iraqi refugees that have emigrated in the past decade- somewhere between 500,000 and 750,000. Proportionate to its current population of 5.8 million, that number is not trivial.[2] The biggest fear is that the population will have doubled by 2030, which is what some demographers have proposed as a worst-case scenario. The Ministry of Health has recognized the growing population trend for quite some time, and has been promoting contraceptive use in order to stymie the fertility rate. In 1984, the fertility level was a staggeringly high 7.3, but by 1996 it had been lowered to 4.6[3], which is still significantly higher than it is today, at 3.42[4]. This is especially impressive when you factor in that over the same time period, infant mortality has decreased significantly as well. Between 1981 and 1991, Jordan had the fastest decrease in infant mortality rate in the world- from 70 to 37 deaths per 1000 births. It has continued to decrease since, and now is about 17 deaths per 1000 births.[5]

Despite government efforts, these numbers have become stagnant over the past few years, which is cause for great concern among officials. In 2002, the fertility rate was 3.7, however it only dropped .01 over a period of 5 years. The 2000-2020 National Population Strategy had expected that it would have been down to 3.2 in 2007, and 2.1 by 2020. A revised goal was set to decrease the rate to 3.1 by 2012. Experts have suggested that the reason this number is not falling as quickly as they had hoped is that women, who are marrying later, are quick to give birth immediately after marriage, completely discontinuing the use of contraception.[6]

Jordan has all of the main modern contraceptive methods available- condoms, pills, IUDs, and injections. The real issue for the fertility plateau is that people are not taking advantage of these options. According to Raeda al Qutob, the secretary general of the Higher Population Council, “Forty per cent of women who use contraceptives discontinue their use within a year. They take pills and stop; they use the IUD which should last for five years and then they remove it after one year. Nearly 30 per cent of women get pregnant when they don’t plan to. They have an unmet need, so what is lacking is the proper counseling.”[7] Health workers and midwives have been trained by the government in order to provide birth control counseling, specifically targeting the population with the highest fertility rates: married couples aged 20-29. USAID has also funded the Jordan Private Sector Project for Women’s Health, which aims “to increase total and modern contraceptive method adoption, decrease contraceptive method discontinuation rates, increase demand for general reproductive health services, increase the frequency of breast screening and self examination, and increase the frequency of cervical examinations and PAP smear.” [8] There are also several non-governmental agencies that are working closely with the Ministry of Health in order to promote the continued use of contraception. Jordan is starting to realize that effort needs to be placed not only in the distribution of contraceptive methods, but the training in how to use them. According to Issa Masarweh, a demographer at the University of Jordan, “There are no full time counsellors, the health centres lack a counselling space and an appointment system and the vast majority of patients show up between 8am and 11am. The heaping of patients over few hours results in low quality services. We need to seize the missed opportunities to provide family planning information whether at the premarital exam, universities, during antenatal care, postnatal care or delivery.”[9]

[1] http://www.marketresearch.com/product/display.asp?productid=2200515

[2] http://www.thenational.ae/news/worldwide/middle-east/jordan-hopes-reproductive-education-will-keep-population-explosion-at-bay

[3] http://www.kinghussein.gov.jo/resources4.html

[4] https://www.cia.gov/library/publications/the-world-factbook/geos/jo.html

[5] https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html?countryName=Jordan&countryCode=jo&regionCode=me&rank=109#jo

[6] [see footnote 2]

[7] [see footnote 2]

[8] http://www.abtassociates.com/collateral/Jordan-PSP.pdf

[9] [see footnote 2]