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Every woman seeking
reproductive health services brings her entire life’s story with her. It
is a story that providers should be prepared to listen to with respect
because it may contain information vital to the woman’s health and
well-being.
Many aspects of a
woman’s life affect her reproductive health, including her relationship
with her partner and her understanding of and beliefs about sexuality.
Because of this, providers would be wise to consider discussing such
issues with clients, says FHI researcher Dr. Patricia Bailey, whose work
has included research on how contraception affects men’s and women’s
quality of life. "The goal of such discussions would be to foster
optimal sexual health, an aim that encompasses much more than just the
prevention of sexually transmitted infections (STIs) or unplanned
pregnancies," Dr. Bailey says.
The World Health
Organization (WHO) defines sexual health as "the integration of the
physical, emotional, intellectual, and social aspects of sexual being in
ways that are enriching and that enhance personality, communication, and
love." Furthermore, WHO states: "Fundamental to this concept are
the right to sexual information and the right to pleasure."1
Violence, coercion,
discrimination, fear, shame, guilt, false beliefs, and lack of knowledge
about sexual issues are barriers to sexual health that many women
throughout the world face. But providers can help by discussing in a
respectful manner with clients aspects of their lives that may impede
optimal sexual health.
"Providing
quality reproductive health care is complex and involves an open dialogue
between providers and clients about issues that traditionally may not have
been discussed during medical consultations," Dr. Bailey says.
| "Providing
quality reproductive health care is complex and involves an open
dialogue between providers and clients about issues that
traditionally may not have been discussed during medical
consultations." |
In-depth interviews
with 15 gynecologists working in primary health care posts in Rio de
Janeiro, Brazil, between 1993 and 1995, for instance, revealed that these doctors
often found it difficult to discuss with female clients issues related to
STIs and sexuality. It was particularly difficult to explain to a married
woman that she had a genital infection and how she might have acquired it,
since such an explanation implied marital infidelity.
"I tell her how
she can avoid complications, but I do not get into how she might have been
infected," said one of the gynecologists. "I do not think it
would be good for her. We do not know how she got infected, and for her to
get ideas ... I think it is best just to treat it."
When physicians in
the study were asked what they typically said to a woman who had an STI,
only half reported informing the client that her infection was transmitted
through sexual contact.
"Look, I try to
be neutral and not get involved in her private life," another
physician said. "I have a very medical posture. I give her the
results of the test and tell her if there is a disease ..."
In the same study,
in-depth exit interviews with 42 women who had been diagnosed with
chlamydia at primary health care posts in Rio de Janeiro where they sought
gynecological and prenatal care revealed that only two of the women
understood that their infection was transmitted through sexual contact.
This suggests that their physicians had not discussed the subject with
them. The 15 gynecologists interviewed for the study did not attend these
women and, in fact, worked at other primary health care posts. But direct
observation of gynecologists working at health posts where the 42 women
were diagnosed revealed that those physicians’ attitudes were similar to
those of the 15 interviewed gynecologists, researchers reported.2
A clear explanation
by a medical professional of the source of STIs is not sufficient to
prevent infection, but it does serve as a foundation for the prevention of
STIs, including HIV/AIDS. Such explanations can be especially important in
settings like Brazil, where heterosexual intimate relations are the
primary mode of HIV infection in women. (In Brazil, the female-to-male
ratio of reported AIDS cases has increased from one female for every 28
males in 1985 to one female for every three males in 1995.)
In the same
Brazilian study, even when clients persisted in attempting to discuss how
they might have acquired an STI — such as through a partner’s
infidelity — some physicians avoided discussing the matter.
According to one
doctor, "When the patient expresses suspicion of infidelity, I cut
her off. ... I say, look here, what is important is that you have a
disease. Both you and your husband have to be treated, right?"
"But providers
should be sensitive to women’s concerns about infidelity," stresses
FHI’s Dr. Bailey, who helped coordinate an FHI Women’s Studies Project
from 1995 to 1996 that examined how contraceptive use affects the
sexuality, quality of life, and stability of couples in El Alto, Bolivia.
Data for the study were collected from focus group discussions and
in-depth interviews with 110 married women and 35 married men from El
Alto.
In one focus group,
several women discussed the impact of their husband’s infidelities.
"No, I don’t like sex," a woman said. "He treats me badly
and he goes with other women. And now he has these large pustules on him.
I don’t know what they are. He’ll disappear for two or three nights
and when I ask him, he always says he was with a friend."3
Exploring
sexuality, relationships
Cultural beliefs
about how active a woman should be in sexual relations can influence how a
woman feels about her sexuality. One-half of the women interviewed in the
El Alto study, for instance, said they did not consider it proper for
married women to initiate sexual relations with their spouses. Many
Bolivian men expressed the same view. However, the male focus group
participants also agreed that one reason they become involved with
extramarital lovers is because, unlike their wives, their girlfriends
initiated sex.4
"Women need to
know that it is normal to be an active participant in sex," Dr.
Bailey says. "A sympathetic and caring provider who brings up the
subject of sexuality with clients and creates an environment where it is
comfortable for clients to talk about sex, can show clients that it is OK
to think about and even articulate these things. Then women might be less
nervous about bringing up the subject with their partners."
| "Women
do not always have the power to make decisions about when they are
going to have sex, how they are going to have sex, and what, if
any, contraceptive method or disease-preventing method they are
going to use." |
There is another key
reason why providers would do well to consider talking with a woman about
her sexuality and relationship with her partner: In some settings,
intimate partner violence can limit a woman’s access to health care or
even prevent her from protecting herself against unplanned pregnancy or
STIs.
A study from 1995 to
1996 of 6,632 married men living with their wives in Uttar Pradesh, India,
found that abusive men were more likely than non-abusive men to have STI
symptoms and to engage in extramarital sex. The study also found that
unplanned pregnancies were more common in abusive relationships.5
"Women do not
always have the power to make decisions about when they are going to have
sex, how they are going to have sex, and what, if any, contraceptive
method or disease-preventing method they are going to use," says Jane
Schueller, FHI’s Associate Director of Training and Education.
"And, if a woman has a partner who has multiple partners outside
their marriage, she is at greater risk of an STI or HIV/AIDS."
Even violence that
has taken place many years ago can affect the reproductive health of a
woman. Research has shown that women who grow up in abusive homes are at
higher risk for unplanned pregnancies.6
That intimate
partner violence is common in many settings is reflected in recent
research. A 1995 population-based, household study of 488 women ages 15 to
49 years in León, Nicaragua, found that 40 percent had been physically
abused by a partner at some point in their lives.7 Another
survey conducted in 1994 among 144 women in Sierra Leone, West Africa,
found that two-thirds of the women had been physically abused by a partner
and more than half had been forced by their partners to have sexual
intercourse. The majority of study participants were recruited from family
planning clinics and hospital clinic waiting rooms in Freetown and in the
Northern Province, but some were also recruited from marketplaces, a
refugee camp, and a teachers’ college.8 And a 1999 study
conducted in the Purworejo District of Central Java, Indonesia, among a
population-based sample of 765 married women who were recruited from a
longitudinal study of health during pregnancy found that one in four had
been physically or sexually abused by her husband.9
Intimate partner
violence can affect a woman’s reproductive health in many ways. In
addition to being at increased risk of an STI and unplanned pregnancy,
abused women are at higher risk for having an induced abortion, pre-term
labor, low birth-weight babies, and various gynecological problems. For
this reason, some experts feel that reproductive health clinics may be an
ideal place to screen for intimate partner violence.
A 1997 FHI survey of
607 women from El Alto and La Paz, Bolivia, supports this premise. Nearly
half of some 40 percent of women who reported experiencing intimate
partner violence said they had visited a reproductive health clinic within
the past year.10
"Reproductive
health services are well-positioned to screen women for intimate partner
violence," says Donna McCarraher, an FHI research associate who
coordinated the FHI study. "But programs that intend to provide
screening need to ensure that everyone in the clinic is thoroughly trained
and committed to preventing intimate partner violence."
Program managers
also need to evaluate whether staff have sufficient time to offer such
services, she says. And policy-makers and program managers need to define
what to do if they identify victims of intimate partner violence through
screening. If they plan to refer women for counseling or shelter, then
program managers need to set up and maintain such a system, McCarraher
says.
It is also important
that programs be evaluated to find out if they are achieving their goals
and really helping women. Finally, McCarraher stresses, even untrained
providers working in settings where screening cannot be done can benefit
from an understanding of how intimate partner violence affects
reproductive health, including contraceptive use. Such an awareness can
help providers monitor their behavior around clients.
"It is
especially important that providers treat clients respectfully, maintain
their confidentiality, and validate their experiences," McCarraher
says. "In this way, providers can become part of the solution and not
make a problem worse."
—
Emily J. Smith
References
- World Health
Organization. Education and Treatment in Human Sexuality: The
Training of Health Professionals. Technical Report Series 572.
Geneva: World Health Organization, 1975.
- Giffin K, Lowndes
CM. Gender, sexuality, and the prevention of sexually transmissible
diseases: a Brazilian study of clinical practice. Soc Sci Med
1999;48(3):283-92.
- Camacho A, Rueda
J, Ordóñez E. Las Mujeres de El Alto se Descubren a sí Mismas:
Impacto de la Regulación de la Fecundidad sobre la Estabilidad de la
Pareja, la Sexualidad y la Calidad de Vida. Research Triangle
Park, NC: Family Health International and Proyecto Integral de Salud,
1997.
- Paulson S.
Cultural bodies in Bolivia’s gendered environment. Int J
Sexuality Gender Stud 2000;5(2):125-40.
- Martin SL,
Kilgallen B, Tsui AO, et al. Sexual behaviors and reproductive health
outcomes: associations with wife abuse in India. JAMA
1999;282(20):1967-72.
- Dietz P, Spitz A,
Anda R, et al. Unintended pregnancy among adult women exposed to abuse
or household dysfunction during their childhood. JAMA
1999;282(14):1359-64.
- Ellsberg MC, Peña
R, Herrera A, et al. Wife abuse among women of childbearing age in
Nicaragua. Am J Public Health 1999;89(2):241-44.
- Coker AL, Richter
DL. Violence against women in Sierra Leone: frequency and correlates
of intimate partner violence and forced sexual intercourse. Af J
Reprod Health 1998;2(1):61-72.
- Hakimi M, Hayati
E, Marlinawati V, et al., eds. Silence for the Sake of Harmony:
Domestic Violence and Women’s Health in Central Java, Indonesia.
Yogyakarta, Indonesia: CHN-RL GMU, Rifka Annisa Women’s Crisis
Center, Umea University, Women’s Health Exchange, Program for
Appropriate Technology in Health, 2001.
- McCarraher D,
Bailey P, Polo T, et al. Determinants of partner violence and the role
of sexual and reproductive health services among women in Bolivia.
Annual meeting of the American Public Health Association, Washington,
DC, November 14-18, 1998.
Training
Providers to Talk about Sex
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Few
providers make discussions regarding sexuality part of their
practice. But research conducted in Egypt through the Population
Council’s Frontiers in Reproductive Health project has shown
that sexuality counseling can be successfully integrated into
services at family planning clinics. The 1999 study was conducted
in four Egyptian Ministry of Health and Population clinics and two
private clinics affiliated with the ministry. Nurses and
physicians from all six clinics attended a two-day contraception
training session emphasizing barrier methods. Staff at three of
these clinics received three additional days of training on
sexuality, gender, and counseling.
To evaluate
the effects of the extra training, the study used a variety of
methods, then looked for consistency in the results. The
researchers conducted exit interviews with 503 clients at both the
control sites and the intervention sites where additional training
had been given. Five focus group discussions were also conducted
with clients. Clinicians’ reactions were obtained via course
evaluation forms that were filled out following the training and
questionnaires completed six weeks after the training. Seven
"mystery" clients who took part in the study, visiting
the intervention and control clinics with fictitious sexual health
complaints, were also interviewed after their visits.
| Nash
Herndon/FHI |
 |
| Integrating
sexuality counseling into family planning services is
rare, but possible. An Egyptian provider and client
discuss family planning. |
Results showed
that medical practitioners who went through sexuality training
were less inhibited about discussing sexuality-related issues with
their clients. Clients attending the intervention clinics were
more likely to have been counseled on how their chosen
contraceptive could affect their sexuality than clients in control
clinics (41 percent versus 22 percent). Clients in intervention
clinics were also more likely to have had a sexuality-related
discussion with their provider unrelated to family planning than
clients in control clinics (44 percent versus 18 percent).
Sexuality discussions in intervention clinics seemed to promote
clients’ adoption of barrier contraceptive methods.
Despite the
extra training, many clinicians reported that they still felt
embarrassed to discuss sexual issues with clients and continued to
think clients with sexual problems should be referred to
specialists. Numerous clinicians also reported that they believed
clients would be too embarrassed to discuss sexual issues with
them. The research results, however, showed the opposite: Three
out of four clients who had a sexuality-related discussion with
their provider in this study said the discussion did not embarrass
them.
"This
study challenges the belief that women do not like to talk about
their sexual problems," said Population Council researcher
Dr. Nahla Abdel-Tawab. "Once rapport is established, they can
talk frankly about sexual difficulties with a physician whom they
trust."1
Many clients
said they preferred to discuss issues related to their sexuality
with a female provider, and many preferred that providers raise
the topic rather than expecting clients to do so. "If the
doctor asks us those (sexuality-related) questions, we would tell
her about our problems, but otherwise I would be embarrassed to
tell her," one client said.2
The most
common concerns raised by clients were pain during sexual
intercourse and loss of sexual desire.
Although
additional training increased communication regarding
sexuality-related issues, some providers were still insufficiently
schooled in treating certain client complaints, according to the
mystery clients. When those clients expressed concern about a loss
of sexual desire, they said some providers concluded that the
problem originated with the woman rather than exploring how a
woman’s social environment, her relationship with her partner,
or other factors might be affecting her sexual desire.
The
study’s authors recommended that providers be trained to manage
simple sexual problems and to counsel women about how various
contraceptive methods can affect sexual relations. They further
recommended that the Egyptian Ministry of Health and Population
develop a referral system with teaching or univer-sity hospitals
for women with more complex sexual problems, and that Egyptian
public health messages encouraging women to ask family planning
providers about their sexuality-related concerns be developed.3
—
Emily J. Smith
References
- Discussing
sexuality in Egyptian clinics is feasible. Popul Briefs
2000;6(4):6.
- Population
Council. Family Planning Providers Should Encourage Clients
to Discuss Sexual Problems. OR Summary. Washington:
Population Council, Frontiers in Reproductive Health, 2000.
- Abdel-Tawab
N. Integrating issues of sexuality into family planning
counseling in Egypt. SIECUS Rep 2001;29(5):25-26;
Population Council; Discussing sexuality in Egyptian clinics
is feasible.
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Life
Circumstances Influence Decisions
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Cultural and
social factors — some obvious, others less so — strongly
influence the reproductive health decisions of women in many
settings throughout the world. A woman’s ability to work and
earn an income that she can control, for instance, can influence
whether she can pay for health services. Religious prohibitions,
expectations that women prove their fer-tility, a woman’s
knowledge and beliefs about contraception, self-esteem,
relationships with friends and family members, and freedom of
movement all influence her decisions. Providers who understand
these influences and establish open and respectful communication
about the circumstances of clients’ lives and decisions help
those clients maintain optimal sexual health.
"Providers
should not forget that many women are living in a context where
they are not making unilateral decisions about their reproductive
health," stresses FHI researcher Dr. Patricia Bailey, whose
work has included research on contraception and quality-of-life
issues.
Research has
found, for instance, that social factors can influence a woman’s
access to reproductive health care and limit her ability to make
decisions about reproductive health issues. In Northern Punjab,
Pakistan, a 1997 study involving in-depth interviews and focus
group discussions with married and unmarried men and women found
that village social systems implemented to protect the honor of
women and their families limited women’s mobility and access to
health care. Unmarried women faced the greatest restrictions and
were often kept at home unless medical care was urgent. Several
respondents also said unmarried women had to avoid frequent visits
to providers, which could suggest a health problem related to
sexual activity.1
A woman’s
position within her extended family has also been found to limit
women’s reproductive health care choices. In rural Bangladesh,
where many families live in grouped dwellings known as "baris,"
a 1994 study found that a woman’s social position within a bari
could limit her access to reversible, modern contraceptive
methods. This study of 2,861 women living in 936 baris found that
daughters-in-law and sisters-in-law of bari leaders had a lower
use of reversible, modern contraceptive methods than wives of bari
leaders. Access to those methods may be limited by either the bari
leader or his wife, the researchers suggested.2
But social
factors do not always have a negative effect on women’s
reproductive health. A recent study in Thailand found that the
more external kinship ties households have, the more likely women
in those households are to use modern forms of temporary
contraception.3 Interpersonal communication through
household kinship networks, both within and outside the village,
may facilitate the spread of information and kinship networks may
provide greater economic resources with which to purchase modern
contraceptive methods, the researchers noted.
"Social
networks really matter," says Dr. Elaine Murphy, senior
program advisor at the U.S.-based Program for Appropriate
Technology in Health, whose work has focused on how
client-provider interactions affect quality of care. "Clients
often hear about family planning services and especially about
specific methods from family members and friends."
Cultural and
social factors also influence women’s knowledge and beliefs
about contraception and reproduction, their self-esteem, and their
feelings about sexuality which — in turn — affect their
reproductive health decisions, research shows.
| Elizabeth
Gilbert/The David and Lucille Packard Foundation |
 |
| A
woman from Nigeria considers her options. Cultural and
social factors can limit reproductive health choices. |
A 1993 study
based on in-depth interviews with 30 indigenous Aymaran women in
La Paz and El Alto, Bolivia, found that many of the women had
ambivalent, if not negative, feelings about sex.4
"The interviews make clear that the women’s reticence to
speak of sexuality and reproduction is something that most of them
learned at an early age," the study’s authors noted.
"They grew up in households where sexuality was not discussed
and they soon learned that it behooved them not to ask questions
or appear to take any interest in such matters."
The study
found that two-thirds of the women were not given clear
information about reproduction when they were growing up and many
did not understand how pregnancy occurs.
"They
learned that sexuality was shameful and dangerous," the
researchers said, "and they were told that they needed to
‘take care of themselves’ and avoid pregnancy, but they were
not told how."
Although the
study did not specifically address whether the women disliked sex,
the researchers reported "an aversion to sex was
apparent." Wives of men who wanted sex infrequently indicated
that they considered themselves lucky.
Such
feelings may have been why the rhythm method and other forms of
family planning involving long periods of abstinence were so
popular among the women, the researchers said. More than half used
some form of the rhythm method. Four of the 30 relied on a
combination of abstinence, prolonged breastfeeding, herbal
infusions to induce menstruation, and abortion. Only eight used
modern contraceptives.
Mistrust of
health care providers may have been another factor influencing the
reproductive health choice of these women, the researchers said.
Many of the women feared modern contraceptives and a number of
them anticipated being discriminated against and receiving poor
treatment because they were Aymaran. Several said that providers
could not be trusted to tell the truth about contraceptive side
effects and reported that providers dismissed their concerns about
these effects.
In some
cases, the women’s mistrust was based on their own past
experiences. Two of the women said they had been pressured into
continuing the use of an intrauterine device (IUD) although they
had asked their providers to remove them because of side effects.
A physician told one of the women, "You’re fine: Healthy as
a girl!"
"That’s
all he said," the woman added, "so I just went
away."
When clients
do not trust providers, they may be less apt to seek out their
services and to obtain from them accurate reproductive health
information that is otherwise unavailable.
This was the
case in the Bolivian study where researchers found that reliance
on natural methods of family planning in the absence of knowledge
about how to use such methods correctly led to many unplanned
pregnancies. Two-thirds of the women had had at least one induced
abortion or had tried to terminate a pregnancy, the study found.
Almost a third reported unplanned pregnancies "that resulted
in the birth of infants who subsequently died in unclear
circumstances that might be interpreted as passive or active
infanticide," the researchers said.
Respectful
communication
Respectful
and open discussions between providers and clients can create
opportunities for providers to learn about factors influencing
clients’ decisions. Wisdom of this sort is necessary for
providers to be able to offer counseling that is truly applicable
to the circumstances of their clients’ lives.
"Only
interactive and dynamic counseling can identify clients’ needs,
risks, concerns and preferences within their life-stage and
life-situation," Dr. Murphy noted in a recent analysis of
client-provider interactions.5 The analysis also
emphasized the importance of individualizing counseling, treating
clients respectfully, counseling on method side effects, and
providing clients with the contraceptive method of their choice.
In the case
of the Bolivian study, where natural family planning methods were
the preference of the majority of the women, the researchers
recommended that providers educate clients to use these methods
effectively rather than trying to convince them to use other
methods.
"Providing
clients with the contraceptive method of their choice is an
important way that medical practitioners can help women maintain
optimal reproductive health," Dr. Bailey agrees. "Women
who have succeeded in getting to a clinic often have a pretty good
idea what they want. Providers should respect that." In fact,
research has shown that a woman who receives her contraceptive
choice is more likely to continue using the method.6
Providing
women with adequate counseling on method side effects can also
improve the chances that women will continue using the method,
research has shown.7 Such observations were confirmed
in a 2001 study conducted in Merida, Yucatan, Mexico, which found
that method continuation rates of the injectable depot-medroxyprogesterone
acetate (DMPA) were substantially higher among women who received
extra counseling on side effects than among those who received
only routine counseling: 83 percent and 57 percent, respectively.8
| "Providers
should not forget that many women are living in a context
where they are not making unilateral decisions about their
reproductive health." |
"Counseling
on side effects is extremely important," Dr. Murphy says.
"Providers should talk with clients about how certain
contraceptives can affect a woman’s body, and also about how
they can affect a woman’s sexual relationship. In some cultures,
for example, where there is a taboo on intercourse during times of
bleeding, IUD use may be discontinued because heavy bleeding and
spotting are frequent side effects of this method. Thus, IUD use
may produce a conflict between a woman’s desire to delay
childbearing and her sexual desires or those of her partner."
Counseling
women, especially youth, about how contraceptive use affects
health, in general, might also prevent some women from making
unhealthy — even life-threatening — sexual health decisions.
Recent research in Benin City, Nigeria, involving focus group
discussions with 149 women ages 15 to 24 found that many young
women believed that modern contraceptive use could cause
infertility and therefore preferred abortion. Many believed that
IUDs could migrate and be lost within a woman’s body, and that
injectables could cause abscess, paralysis, or infertility.
Although unsafe abortion is the leading cause of maternal
mortality in Nigeria, with 80 percent of the deaths occurring
among youth, the study still found that most of the focus group
participants felt that abortion was less risky than the use of
modern contraception.9
—
Emily J. Smith
References
- Khan A.
Mobility of women and access to health and family planning
services in Pakistan. Reprod Health Matters
1999;7(14):39-48.
- Kamal N,
Sloggett A, Cleland J. Area variations in use of modern
contraception in rural Bangladesh: a multilevel analysis. J
Biosoc Sci 1999;31(3):327-41.
- Godley J.
Kinship networks and contraceptive choice in Nang Rong,
Thailand. Int Fam Plann Perspect 2001;27(1):4-10, 41.
- Schuler
S, Choque M, Rance S. Misinformation, mistrust, and
mistreatment: family planning among Bolivian market women. Stud
Fam Plann 1994;25(4):211-21.
- Murphy E.
Client-provider interactions in family planning services:
guidance from research and program experience. In Recommendations
for Updating Selected Practices in Contraceptive Use, Volume
II. Washington: U.S. Agency for International Development,
1997.
- Pariani
S, Heer DM, Van Arsdol MD Jr. Does choice make a difference to
contraceptive use? Evidence from East Java. Stud Fam Plann
1991;22(6):384-90; Huezo C, Malhotra U. Choice and
Use-Continuation of Methods of Contraception: A Multicentre
Study. London: International Planned Parenthood
Federation, 1993.
- Cotton N,
Stanback J, Maidouka H, et al. Early discontinuation of
contraceptive use in Niger and The Gambia. Int Fam Plann
Perspect 1992;18(4):145-49; Lei Z, Wu S, Garceau RJ.
Effect of pretreatment counseling on discontinuation rates in
women given depot-medroxyprogesterone acetate for
contraception. Chung Hua Fu Chan Ko Tsa Chih
1997;32(6):350-53; Thom NT, Anh PT, Larson A, et al.
Introductory study of DMPA in Vietnam — an opportunity to
strengthen quality of care in family planning service
delivery. Lessons Learned Workshop, Hanoi, October 12,
1998.
- Canto De
Cetina T, Canto P, Luna M. Effect of counseling to improve
compliance in Mexican women receiving depot-medroxyprogesterone
acetate. Contraception 2001;63(3):143-46.
- Otoide
VO, Oronsaye F, Okonofua FE. Why Nigerian adolescents seek
abortion rather than contraception: evidence from focus-group
discussions. Int Fam Plann Perspect 2001; 27(2):77-81.
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