Papers
DownloadFactors that shape young people's sexual behaviour: a systematic review
with Eleanor King
BACKGROUND: Since nearly half of new HIV infections worldwide occur among young people aged 15-24 years, changing sexual behaviour in this group will be crucial in tackling the pandemic. Qualitative research is starting to reveal how social and cultural forces shape young people's sexual behaviour and can help explain why information campaigns and condom distribution programmes alone are often not enough to change it. We undertook a systematic review to identify key themes emerging from such research, to help inform policymakers developing sexual health programmes, and guide future research. METHODS: We reviewed 268 qualitative studies of young people's sexual behaviour published between 1990 and 2004. We developed a method of comparative thematic analysis in which we coded each document according to themes they contained. We then identified relations between codes, grouping them accordingly into broader overall themes. Documents were classified as either primary or secondary depending on their quality and whether they contained empirical data. From the 5452 reports identified, we selected 246 journal articles and 22 books for analysis. FINDINGS: Seven key themes emerged: young people assess potential sexual partners as "clean" or "unclean"; sexual partners have an important influence on behaviour in general; condoms are stigmatising and associated with lack of trust; gender stereotypes are crucial in determining social expectations and, in turn, behaviour; there are penalties and rewards for sex from society; reputations and social displays of sexual activity or inactivity are important; and social expectations hamper communication about sex. The themes do not seem to be exclusive to any particular country or cultural background, and all themes were present, in varying degrees, in all countries assessed. INTERPRETATION: This study summarises key qualitative findings that help in understanding young people's sexual behaviour and why they might have unsafe sex; policymakers must take these into account when designing HIV programmes. Considerable overlap exists between current studies, which indicates the need to broaden the scope of future work.
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Effects of contraception on obstetric outcomes
with John Cleland.
The contribution of contraception to reductions in obstetric
mortality and morbidity is universally acknowledged.
One major pathway is by reducing the number
of unwanted births. Each pregnancy and childbirth
carry a health risk for the woman, and where obstetric
services are poor, maternal mortality is still very high.
In most Asian and Latin American countries for which
relevant evidence exists, it is estimated that about 20%
of births were unwanted at the time of conception. In
Africa, where desired family sizes tend to be relatively
high, the prevalence of unwanted births is typically
lower, closer to 10%. On the assumption that unwanted
births carry the same risk to the health of the mother
as wanted births, it has recently been estimated that
the global burden of disease attributable to unwanted
births amounts to 4.6 million disability-adjusted life
years (DALYs) (Collumbien et al., 2002). Better use of
effective contraception would reduce this substantial
burden. In the extreme scenario, where all women who
wanted to stop having children used effective methods
of contraception, the burden would be eliminated, but
for a small residue resulting from contraceptive failure.
Does contraception contribute to better maternal health
beyond its potential to reduce the proportion of births
that are unwanted? The answer depends on the extent
to which births averted by contraception would otherwise
pose a greater risk to the mother than wanted
or intended births. The risks of childbirth are known to
vary with the mother’s age and may also be linked to
her parity and to the interval since the previous birth.
Contraception is likely to change the age pattern of
childbearing, particularly by reducing fertility at older
ages, and will certainly affect parity-specific fertility. The
first section of this paper reviews the evidence for the
assertion that contraception benefits maternal health
by reducing the number of high-risk births. The second
section examines a related possibility—that unwanted
births represent a greater threat to the mother’s health
than wanted births because less time and money are
invested in antenatal and natal care. Lack of antenatal
care and, to a greater extent, lack of skilled medical
supervision during delivery are established risk factors
for poor obstetric outcomes. This section presents
new evidence on the link between unwantedness and
obstetric care.
The second major contribution of contraception to reducing
obstetric mortality and morbidity is related to
its potential to diminish recourse to unsafe abortion.
Globally, it is estimated that 22% of pregnancies are
aborted (Alan Guttmacher Institute, 1999). By definition
these pregnancies are unwelcome, in the sense of
being either absolutely unwanted or mistimed (i.e. the
mother may want to have a child at some future date
but not at the time of conception). In most industrialized
countries, abortion is legally permitted for a wide
variety of reasons, is performed by properly trained
staff and carries very little risk to the physical well-being
of the mother. Conversely, in most African and Latin
American countries and in many Asian countries, abortion
is legally permitted only in extreme circumstances
and the vast majority of abortions performed are illegal.
It has been estimated that in 2000 19 million illegal/unsafe
abortions were carried out, of which 18.5 million
were in developing countries (Ahman & Shah, 2002).
Abortion legality and safety are strongly correlated.
When a pregnancy is terminated by someone lacking
the necessary skills or in an environment that does not
conform to minimum standards of hygiene, the woman
is at a higher risk of serious complications. Globally,
it is estimated that about 13% of pregnancy-related
and birth-related deaths in women are caused by
unsafe abortion. While it might seem self-evident that
greater use of contraception will lead to a reduction in
abortions—both safe and unsafe—this link has been
challenged and, indeed, it is true that rising levels of
contraceptive use can be accompanied by a rising incidence
of abortion. The third section of this paper uses
published data to re-examine the relationship between
changes in contraceptive practice and abortion rates.
Do unintended pregnancies carried to term lead to adverse outcomes for mother and child? An assessment in five developing countries
with John Cleland
This paper investigates whether children later reported as having been unwanted or mistimed at conception will, when compared with children reported as wanted, show adverse effects when the following criteria are applied: receipt of antenatal care before the sixth month of gestation, supervised delivery, full vaccination of the child, and child growth (stunting). The study uses data from five recent Demographic and Health Survey enquiries in Bolivia, Egypt, Kenya, Peru, and the Philippines. In Peru, children unwanted at conception were found to have significantly worse outcomes than other children, but in the other countries, a systematic effect was found only for receipt of antenatal care. Weak measurement of the complex concept of wantedness may have contributed to these results. Birth order of the child, with which wantedness is inextricably linked, has more powerful and pervasive effects, with first-born and second-born children being much less likely to show adverse effects.
