Abstracts of Free Communications

FC1-01

Initiatives to improve uptake of effective contraception after emergency contraception from the pharmacy: A pilot study

L. Michie¹, S. Cameron¹, A. Glasier², A. Johnstone¹, D. Milne¹ & E. Chen²

¹Chalmers Sexual Health Centre, Edinburgh, UK

²University of Edinburgh, Edinburgh, UK

Design and methods: Twelve community pharmacies in Edinburgh were randomised to provide POP or rapid access or standard care to women presenting for EC who wished to participate in a pilot study. Participants agreed to be contacted by telephone six to eight weeks later by a researcher to determine current contraceptive use. In-depth interviews were conducted with a subset of 12 women about their experiences of the intervention received.

Results: A total of 136 women agreed to participate, of whom 109 (80%) were subsequently contactable. Of those contacted, 84 (62%) women completed the telephone interview. The average age was 24 yrs and the commonest reason for requesting EC was a condom failure (58%). A total of 29/32 women in the POP arm (91%) used the pills provided and 10/26 women (38%) in the rapid access arm attended the FPC. Compared to the women receiving standard care, the proportion of women using effective contraception six to eight weeks after EC use was significantly greater in both the POP (53% vs. 25% p = 0.032) and in the rapid access groups (52% vs. 25% p = 0.053). Women were positive about obtaining EC from the pharmacy and felt that the POP and rapid access interventions were valuable.

Conclusion: The supply of one month of a POP after EC or rapid access from a pharmacy to a FPC are feasible interventions and both might increase uptake of effective contraception following EC. Larger confirmatory studies are now required.

FC1-02

Socio-cultural factors affecting women's sexual health and contraceptive use in southeast Madagascar

J. Morris, M. Andriatsihosena, S. Short

Azafady, Fort Dauphin, Anosy, Madagascar

Objectives: To explore the socio-cultural barriers to women's health, including access to quality services and uptake of health promoting behaviours with particular reference to sexually transmitted infection (STI) prevention and treatment and contraceptive use to inform the development of a local non-governmental organization (NGO) maternal health intervention projects.

Method: The study was set in Fort Dauphin, the urban centre of Anosy Region in southeast Madagascar. It spanned 12 months and utilised both qualitative and quantitative research methods. Qualitative data included focus groups, interviews and longitudinal case studies; the sample was purposefully selected and consisted of 256 pregnant women, mothers of children under five, male partners, family elders, formal and informal health workers, government ministry representatives, community leaders and partner agency representatives. Audio-recorded data was transcribed, translated and manually coded for predetermined and emerging themes. Quantitative data included a random household survey of 373 women of reproductive age. Survey data was entered into Epi Info and analysed using STATA software. Data was synthesised and themes corroborated with stakeholders.

Results: Thirty percent of pregnant women tested positive for syphilis; other STI rates were similarly high. Knowledge of prevention was low at 8% as was consistent use of condoms – 15% for women with casual partners and 6% for women with a stable partner. Barriers to sexual health fit into three socio-cultural themes: (1) lack of knowledge and services, (2) myths and misconceptions, and (3) sex and relationship norms. A high rate of contraceptive awareness and use was found, however this was off-set by low adherence to and understanding of correct use of method employed. Three themes preventing effective use of contraception were identified: (1) influence of husbands and family, (2) improper use of method, and (3) actual and perceived side effects of hormonal contraceptives including reduced fertility.

Conclusions: The data revealed that social and cultural beliefs and norms impact heavily on women's ability to protect themselves from STIs and unwanted pregnancies, contributing to high local incidence of maternal mortality and morbidity. Recommendations include expanding reproductive health education into the community, incorporating influential community members and tailoring messages to family elders and men about the benefits of family planning and sexual health, male-targeted interventions for prevention, testing and treatment of STIs, condom promotion and improved public health services. Findings supported the development of a maternal health strategy and associated interventions for a local NGO, and establishment of a regional maternal health stakeholder platform.

FC1-03

Providing medico-legal services to women and girl survivors of sexual violence: Perspectives of service providers in Addis Ababa, Ethiopia

M.A. Woldetsadik¹, T. Alemu², S.H. Hobbs³, S. Simon⁴

¹Ecole des Hautes Etudes en Santé Publique, Rennes, France, ²UN Women Liaison Office to the African Union and United Nations Economic Commission for Africa, Addis Ababa, Ethiopia, ³UNC Gillings School of Public Health, North Carolina, USA, ⁴Médecins du Monde, Paris, France

Background: In addition to causing physical injury, sexual violence increases women and girls’ long-term risks for a number of sexual and reproductive health problems. A large body of evidence has shown the long lasting impact of gender-based violence on women's health including, but not limited to fatal outcomes such as maternal mortality and suicide; acute and chronic physical injuries such as obstetric complications and unsafe abortions and a range of gynecological problems. Research in Ethiopia is very limited when it comes to the nature and magnitude of sexual violence against women and girls as well as service provision to survivors.

Objective: The aim of this study was to investigate the various factors that affect provision of medico-legal services to women and girl survivors of sexual violence from the perspective of service providers, including healthcare and legal professionals at a government hospital specialised in maternal and neonatal healthcare in Addis Ababa, Ethiopia.

Methods: Qualitative semi-structured interviews and non-participant observations were used as the primary source of data collection. A total of 14 key informants with at least one year of fulltime work experience in provision of services to women and girl survivors were invited to participate in this study. Maximum variation sampling was employed to include the perspective of service providers in different job categories and also varied across age, gender and years of experience. The interviews were analysed using conventional content analysis.

Results: Four major thematic categories emerged in regards to factors affecting service provision: provider-related factors, institutional-related factors, culture-related factors and factors related to the legal environment. Within each category, various sub-themes were identified and explored in detail. Participants also identified key entry points for improving services.

Conclusion: This study revealed various barriers to providing comprehensive services, including reproductive and sexual health services and counselling at individual, institutional and societal levels. Most of the obstacles identified can only be tackled through a holistic approach that takes into account the social, economic, cultural and legal factors that affect service provision to survivors of sexual violence. The commitment and involvement of the government as well as other stakeholders including service providers, communities, policymakers and survivors is detrimental in improving service provision. More research is needed to understand the perspective of sexual violence survivors so that services can be provided in a way that is most helpful to them.

FC1-04

Validity and reliability of the Sexual Health Education for Adolescents (SHEA) questionnaire

R. Nordin, C.Y. Chong, Z.M. Low, C.M. Chung, C.Y.T. Wong

Clinical School Johor Bahru, Monash Univeristy Sunway Campus, Johor Bahru, Malaysia

Introduction: The Sexual Health Education for Adolescents (SHEA) questionnaire is the English version designed to measure the knowledge, attitude, and practice (KAP) of sexual health among adolescents.

Objectives:

(1) To convey abstinence as a sexual health choice amongst teenagers aged 15 to 18.

(2) To provide an avenue for teenagers to relay questions and concerns.

(3) To instil knowledge on sexual appropriateness.

(4) To provide knowledge on pubertal changes.

(5) To introduce a model sexual health curriculum for secondary school students in Malaysia.

(6) To create a pre- and post-questionnaire regarding the sexual health education talk.

(7) To assess the effectiveness of the sexual health education talk using the pre- and post-questionnaire.

(8) To assess the validity of the questionnaire.

Materials and methods: The SHEA questionnaire consists of 60 questions (true/false, yes/no) on knowledge about sexual development, attitudes toward, and practices of sexual health among adolescents in Malaysia. Content validity was established following expert review of the questionnaire. We evaluated the psychometric properties of the SHEA questionnaire among adolescents in a secondary school in Johor Bahru. The questionnaire was piloted among 200 secondary school girls in order to evaluate the construct validity and internal consistency (reliability) of the survey instrument. Construct validity was assessed using exploratory factor analysis whilst reliability was determined using Cronbach's alpha. Statistical analysis was undertaken using the IBM SPSS Statistic version 20.0 located in the Clinical School Johor Bahru.

Results: Exploratory factor analysis showed three meaningful common factors that could explain 21.7% of the variance underlying the theoretical constructs of knowledge (19 items), attitude (16 items), and practice (13 items) of sexual health among adolescents. Cronbach's alpha coefficients were acceptable for knowledge (0.744), attitude (0.767) and practice (0.604) of sexual health.

Conclusion: The SHEA questionnaire is a valid and reliable instrument for measuring the KAP of sexual health among adolescents.

FC1-05

Postpartum and postabortum contraception: A family planning program in Indonesia

M.I. Apriansyah

National Population and Family Planning Board, Jakarta, Indonesia

Objectives: To explore preferences of acceptors in using contraceptive methods during postpartum and postabortum periods in Indonesia by type of contraception and regions.

Method: Research subjects were postpartum and postabortum acceptors involving about 80,810 women from 727 hospitals in Indonesia. Selected hospitals were determined by the hospital family planning program (HFPP). This research used a survey approach based on the hospital's reporting and recording data from January to December 2011. Indonesia, which has 33 provinces divided into five regions, consists of the regions of Sumatera (10 provinces), Java-Bali (7 provinces), Kalimantan (4 provinces), Sulawesi (6 provinces), and Nusa Tenggara-Maluku-Papua's (NTMP) (6 provinces).

Results: The results show that the main contraceptive type used nationally is injection (31.5%), and that the Java-Bali region had the highest contraceptive use (41.6%). The highest prevalence of vasectomy was in the Sumatera region (53%), the highest prevalence of tubectomy was in Java-Bali (46.9%), the highest prevalence of IUD use was in Java-Bali (52.2%), the highest prevalence of implants were in Sumatera (53.7%), the highest prevalence of injection was in Java-Bali (41.7%), the highest prevalence of the pill was in Sumatera (47.1%), and the highest prevalence of condom use was in the Java-Bali region (46.3%).

The most common type of contraceptive use in Sumatera was injection (30.7%), and the second was the pill (18.5%). The most common type of contraceptive use in Java-Bali was injection (31.5%), and the second was the IUD (19.8%). The most common type of contraceptive use in Kalimantan was injection (30.1%), and the second was the condom (21.1%). The most common type of contraceptive use in Sulawesi was injection (34.1%), and the second was the pill (18.8%), and the most common type of contraceptive use in NTMP was injection (33%), and the second was the IUD (24.2%).

Conclusion: In order to improve the situation, health authorities should be encouraged to provide counselling on postpartum and postabortum contraceptive methods during ante and postnatal care. Targeted behaviour change in communication using community workers is an effective and feasible strategy for promoting postpartum and postabortum contraception. Health providers also should elevate promotion of all types of contraception and increase understanding of women and men in reproductive age. This finding brings important information to light about the use of contraception in the five different regions. The government should take this as valuable material to increase maternal health in Indonesia.

FC2-06

Efficacy, safety and acceptability of a new contraceptive vaginal ring delivering 150 μg Nestorone^® and 15 μg Ethinyl Estradiol daily: Results from a multi-center open label Phase 3 clinical trial

R. Merkatz¹, K. Roberts¹, E. Hoskin¹, H. Sussman¹, D. Apter², L. Bahamondes³, E. Banks⁴, G. Bártfai⁵, V. Brache⁶, H. Croxatto⁷, P. Darney⁸, I. Frasier⁹, K. Gemzell Danielsson¹⁰, M. Gilliam¹¹, M. Miranda⁷, D. Mishell¹², D. Portman¹³, J. Steinauer⁸, E. Weisberg⁸, R. Sitruk-Ware¹

¹Population Council, New York, NY, USA, ²Family Federation of Finland, Helsinki, Finland, ³University of Campinas, Campinas, Brazil, ⁴Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA, ⁵Albert Szent-Györgyi Medical University, Szeged, Hungary, ⁶Profamilia, Santo Domingo, Dominican Republic, ⁷Instituto Chileno de Medicina Reproductiva, Santiago, Chile, ⁸San Francisco General Hospital, UCSF, San Francisco, CA, USA, ⁹FPA Health, Sydney, Australia, ¹⁰Karolinska Hospital, Stockholm, Sweden, ¹¹University of Chicago Hospitals, Chicago, IL, USA, ¹²University of Southern California Medical Center, Los Angeles, CA, USA, ¹³Columbus Center for Women’s Health Research, Columbus, OH, USA

Objectives: The Nestorone^®/Ethinyl Estradiol Contraceptive Vaginal Ring (NES/EE 150/15 CVR) is a new, user- controlled, long-acting contraceptive method that can be reused for up to one year and does not require refrigeration during periods of non-use. It is inserted into the vagina by the woman, left in place for 21 days and removed for 7 days each cycle for up to 13 cycles. This combined hormonal contraceptive contains NES, a novel non-androgenic progestin shown to have potent antiovulatory effects at low doses. Data from the multi-centre, multinational Phase 3 trial demonstrate that the CVR is easy to use by women with varying demographic characteristics. It holds the promise of providing an additional contraceptive choice for women from diverse regions where unmet need for contraception remains high.

Method: A total of 1135 healthy normally ovulating women aged 18 to 40 were enrolled and followed for one year from 12 multinational sites. Primary objectives were to determine efficacy and safety during 13 cycles of use; secondary objectives included evaluation of cycle control, bleeding, and acceptability.

Results: The Pearl Index (PI), the main marker of efficacy, and life table analyses demonstrated that this CVR is comparable to recently approved contraceptives. Significant regional differences were observed in European and Australian sites, producing the lowest PI (0.43). Bleeding patterns were highly favourable at all sites. Mean and median number of scheduled bleeding and/or spotting days per cycle per subject were both 4.6 (SD = 1.4). Reports of unscheduled bleeding episodes during the ring-in period were infrequent. All 143 qualifying subjects reported a return to fertility, defined as pregnancy or vaginal bleeding occurring more than 18 days after last CVR use.

Results from the acceptability study indicated that most women were satisfied with this method, found it easy to use, were willing to use it in the future and recommend it to others. Women who discontinued early were more apt to have difficulties adhering to instructions for use. Overall one year continuation rates were 69%.

The safety profile of the NES/EE CVR appears consistent with currently available hormonal contraceptives including reports of adverse events commonly associated with hormonal contraceptives. There was one venous thromboembolism (VTE) that occurred in a US site.

Conclusion: Results from this Phase 3 trial suggest the NES/EECVR is a safe, effective, convenient and acceptable new contraceptive method. The Council is preparing a New Drug Application for submission to the FDA and other health authorities.

FC2-07

The PrePreg network – an international research network within preconception health and care

M. Ekstrand¹, J. Stern², M. Larsson³, J. Shawe⁴, H. Hegaard⁵, B. Kjeldberg Magnussen⁶, I. Delbaere⁷, P. Mastroiacovo⁸, I. Mogilevkina⁹, R. Klemetti¹⁰, B. Jack¹¹, C. Sigurdson Christiansen¹², R. Bortolus¹³, T. Tydén²

¹Department of Care Science, Malmö University, Malmö, Sweden, ²Department of Public Health and Caring Science, Uppsala University, Uppsala, Sweden, ³Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden, ⁴Institute for Women´s Health, UCL, London, UK, ⁵Department of Women's and Children's Health, Juliane Marie Center, Copenhagen, Denmark, ⁶University College of Northern Denmark, Århus, Denmark, ⁷Department of Public Health, University of Ghent, Ghent, Belgium, ⁸ICBD – Alessandra Lisi International Centre on Birth Defects and Prematurity – WHO Collaborating Centre, Rome, Italy, ⁹Departments of Obstetrics and Gynecology, University Hospital Donetsk, Donetsk, Ukraine, ¹⁰National Institute for Health and Welfare, Helsinki, Finland, ¹¹Department of Family Medicine, Boston University, Boston, USA, ¹²Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland, ¹³Research Promotion Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy

Objectives: Preconception care is important for screening, prevention and management of risk factors that affect pregnancy outcomes and the future health of mother and child. The PrePreg Network was formed of researchers and clinicians in October 2010 as a reaction to the need of a network undertaking preconception care research across Europe. Since then, the PrePreg Network has continuously grown and participating members are from countries such as Sweden, Denmark, Norway, Finland, Great Britain, The Netherlands, Belgium, France, Italy, Ukraine and USA.

Aims: The aims are to increase health promoting behaviour in relation to pregnancy planning and the understanding of the bio-psychosocial, cultural and economic factors affecting pre-pregnancy care. Several research topics have been initiated, such as (i) a baseline comparison of current policies, guidelines and recommendations for pre-pregnancy care in Europe, (ii) a study about health, lifestyle habits and maternal wellbeing both prior to conception and during and after pregnancy, and (iii) a study investigating the attitudes towards pregnancy planning and fertility among patients, and (iv) evaluation of the so called Reproductive Life Plan as a tool for reproductive health.

Conclusion: We believe that the Prepreg Network will have a substantial impact within the field of preconception health and care. We see the First global congress on contraception, reproductive and sexual health as an opportunity to present the Prepreg network, its aims and ongoing projects to a vast number of professionals within the field.

FC2-08

Increasing access to long acting reversible contraception in Australia: Time for a change?

D. Bateson¹, C. Harvey², K. Black³

¹Family Planning New South Wales, Sydney, NSW, Australia, ²Family Planning Queensland, Brisbane, QLD, Australia, ³University of Sydney, Sydney, NSW, Australia

Objectives: To examine the use of long acting reversible contraception (LARC) in Australia based on available data, to explore barriers to LARC uptake, and to identify strategies to address these barriers. Available Australian data suggest a relatively high rate of teenage fertility and abortion compared to northern European countries.

Method: We examined existing survey and other data sources for rates of use of LARC methods and explored reasons for low LARC uptake through a survey of women attending for intrauterine device insertion in the family planning setting and a survey of gynaecologists’ knowledge of intrauterine contraception.

Results: While systematic nationally representative data collection is lacking, a population-based 2002 survey found only 1.2% of women were using intrauterine contraception (IUC), 1.1% an implant and 1.5% an injectable method. Recent prescription data suggest a modest increase in uptake but a 2011 study of 114,000 Australian general practice consultations indicated that only 15.4% of all contraception consultations relate to LARC.

A survey of 366 women attending family planning clinics in New South Wales and Queensland for IUC insertion, found almost one fifth had been told it was unsuitable by a health professional, a friend or a family member, despite meeting appropriate medical eligibility criteria for insertion. In a 2008 survey of 701 Australian gynaecologists, only 39.1% considered the copper-bearing IUC suitable for nulliparous women compared to 62.3% for the hormonal-IUC.

Conclusions: Reasons for low use of LARC appear to include lack of information and misinformation, both in the community and amongst healthcare professionals. Access and cost-related issues may also impact on uptake and require further investigation. Women living in rural and remote areas may need to travel large distances to find an appropriately trained practitioner. While injectables, implants and the hormonal-IUC are government subsidised at point of purchase, additional insertion-related costs of implant and IUC methods may act as a deterrent to uptake. The copper-IUC is not subsidised and requires a private prescription.

Strategies to increase LARC uptake could include evidence-informed promotion at a community and provider level, a review of training needs and incentives for provision in general practice. It is time for Australia to consider promotion of LARC methods as a national health priority, particularly for young women.

FC2-09

Distribution of HPV genotypes and related cervical dysplasia in adolescents in Belgium

M. Merckx¹, S. Weyers¹, J. Meys², C. Depuydt³, M. Temmerman⁴, D. Vanden Broeck⁵

¹Ghent University Hospital, Department of OB/GYN, Ghent, Belgium, ²Department of Applied Mathematics, Biometrics and Process Control, Faculty of Bioscience Engineering, Ghent University, Belgium, ³Laboratory for Clinical Pathology, Labo Lokeren, campus RIATOL, Antwerp, Belgium, ⁴World Health Organization (WHO), Geneve, Zwitzerland, ⁵International Centre for Reproductive Health, Ghent University, Ghent, Belgium

Background and introduction: HPV infections are well known to be very common in reproductive age women. The acquirement is usually related to sexual behaviour. The viral infection is causally related to cervical cancer. HPV contamination is not age related, both adults and underaged girls are subject to infections, and HPV is a source of morbidity worldwide. Information on the frequency of HPV genital infections in adolescents is sparse, and there are no data available on the genotype specific distribution. Nonetheless, as data from girls below 18 are lacking, recommendations about the onset of a screening program remain uncertain. Therefore, the aim of the current retrospective study was to gain insight in the different genotypes, their specific distribution and the new trends in genotype prevalence since vaccination below 18.

Methods: This observational retrospective study included 4180 samples of patients presenting themselves for opportunistic screening in Belgium between June 2006 and January 2012. Samples were collected in liquid based cytology medium and analyzed using a series of genotype specific real time PCR reactions. Cytology was read with prior knowledge of HPV infection and scored using the Bethesda classification.

Results: Among the 4180 patients, a majority presented themselves spontaneously for screening (n = 4160, 99.5%). The mean age was 16.9 years. Most youngsters had no complaints (88.4%), were using hormonal contraception (79.5%) and clinical examination did not show any abnormalities (96.0%). Samples were taken by the gynaecologist (79.5%) and to a lesser extent by the general practitioner (15.0%). Overall HPV prevalence was 15.1%, with the most frequently found HPV types being HPV51 (17.2%), HPV16 (16.4%), HPV66 (11.2%), HPV31 and HPV39 (both 8.0%). HPV infections were more commonly found with increasing age, and also multiple infections were more frequently present with older patients. More than one third of the youngsters (37.6%) harbored an infection with at least two HPV genotypes. The prevalence of high risk types increased with age, ranging from 4.7% in the girls under the age of 14 years up to almost 25% of the 17 year olds. Cervical abnormalities were seen in 8.2% of included patients. Among those lesions, LSIL (4.2%) was most frequently seen, followed by ASC-US (3.6%), HSIL (0.3%), and ASC-H (0.1%). Severity of lesions worsened also with an increasing age.

Conclusion: Our data of girls under 18 that presented themselves for opportunistic cervical screening, confirm that multiple HPV-type infection in these young girls is extremely common. The number of cervical abnormalities is high, with an overall occurrence of H-SIL and L-SIL. Considering this high occurrence we should start wondering whether systematic screening at an age of 25 comes too late. Our findings indicate that an aberrant HPV genotype profile can be found in adolescent women, and that this group is highly frequently infected with HPV harboring cervical abnormalities. Meanwhile there is a widespread consensus that adolescents have specific health related problems and their needs are different from the adult population in many ways. Optimal clinical management of youngsters has to be considered, they also need an appropriate education about HPV and the consequences of getting infected.

FC2-10

Hormonal contraception and hemorrhagic stroke: A national follow-up study 2001–2010

Ø. Lidegaard, C.W. Skovlund, L.H. Nielsen, L. Poulsgaard

Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

Objectives: Several new types of hormonal contraception have emerged since the latest studies on the influence of such products on the risk of hemorrhagic stroke were conducted. We aimed to provide an update including newer types of hormonal contraception.

Methods: A historical registry based cohort of non-pregnant Danish women 15 to 49 years old, free of previous cardiovascular disease or cancer, were followed from January 2001 through December 2010. Exposure data, clinical end points and potential confounders were retrieved from four National Registries and analysed with Poisson regression.

Results: After exclusions, 1,626,158 women contributed with 9,429,128 observation years, of these 3,532,742 years (37.5%) of current use of some kind of hormonal contraception. During the 10-year follow-up period, 1444 first ever hemorrhagic strokes were observed, 884 subarachnoid haemorrhages (SAH) and 560 intracerebral haemorrhages (ICH). With non-users as reference, current use of combined oral contraceptives with 30–40 μg ethinylestradiol conferred relative risks (RR) of SAH of 1.3 (95% CI 1.1–1.6) for ICH 1.2 (1.0–1.5). The corresponding results for 20 μg pills were 1.3 (0.9–1.7) and 1.0 (0.7–1.4), respectively. Progestogen-only contraception did not confer any increased risk, and we found no consistent difference in risk according to oral contraceptives with different progestogens.

Conclusion: Combined pills with 30–40 μg estrogen increase the risk of SAH by 25 to 29% and of ICH less, if at all. Progestogen-only contraception does not confer an increased risk of hemorrhagic stroke.

FC2-11

Religion, fertility intention and contraceptive use: A study of couples in a peri-urban community of south western Nigeria

P. Ogunjuyigbe, A. Oladosu, A. Akinlo, E. Orji, A. Adeyemi

Obafemi Awolowo University, Ife, Osun State, Nigeria

Objective: To examine the interrelationship between religion, fertility intention and contraceptive use.

Methods: This study is based on the baseline data from a longitudinal couple study in a peri-urban community, Ipetumodu, in Osun State, Nigeria collected between April and May, 2010. This study is part of a multi-country Family Health and Wealth Study (FHWS) in seven peri-urban communities in the five sub-Saharan African countries of Ethiopia, Ghana, Malawi, Nigeria and Uganda. The study is coordinated by the Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins University, USA. Ipetumodu is located northwest of Ile-Ife and is the headquarters of Ife North Local Government Area of Osun State, Nigeria. This community has a total population of 20,472 and 4,950 households. A total of 800 couples were sampled in this baseline. After data cleaning, only 784 couples have complete data and this paper is based on this number. The data have been analysed at both univariate and bivariate levels.

Results: The findings indicate that though the average number of children per couple has decreased slightly, the proportion of couples desiring higher number of children is still high. Contrary to the situation elsewhere in the country, the disparity between the adherents of Christianity and Islam in the area is not significant. About equal numbers prefer a large family size and the reasons for desiring more children are similar ranging from religious and moral reasons, economic/financial reasons to the wish of the male partners. But the study further shows that religion plays a major role in couple’s decision for more children and more of the Muslim couples are not sure of their future fertility intentions. As it concerns the use of contraceptives, more of the Christians are more favourably disposed to the use of family planning. More of the followers of Islamic religion compared to Christians are not using methods and do not intend to use contraceptives in the future with the commonest reason given for this attitude being religion.

Conclusion: Religion is important in couples’ fertility desires and in their intentions to use or not to use family planning.

FC2-12

Medical education in family planning

U. Landy, J. Steinauer

Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA

Objectives: In 2010, the Commission on Education of Health Professionals for the 21st century published a report in The Lancet tracing the history of medical education and analysing the future needs of the medical workforce. The Commission found that the medical education system requires substantial reform to reflect changing technology, innovations in education, and the health needs of the 21st century. Key concepts are competency-based education, which emphasises clinical skills that can be measured and assessed, evidence-based practice and professionalism. Family planning education represents a unique opportunity for meeting those educational objectives.

Methods: We reviewed the approach pioneered in the United States of integrating family planning education, a 12-year national initiative including 65 obstetrics and gynaecology residency programmes. We analysed outcomes based on the educational objectives set by the Council of Resident Education for obstetricians and gynaecologists which included clinical skills, professionalism and evidence-based practice based on pre- and post-rotation evaluations, feedback from residency programme directors and expert teaching faculty. In addition, we reviewed educational methods and specific elements of teaching approaches and institutional settings.

Results: Systematic integration of family planning education relies on professional mandates, institutional support, expert faculty and clearly defined outcome measures.

Over 2000 residents have been trained to competency in all methods of uterine evacuation and contraception since the inception of the programme in 1999. Including Family Planning into clinical and didactic training of students and residents increases the future practitioners’ ability to evaluate evidence and to integrate such evidence into future practice. It allows focus on new evidence, i.e, timing and patient eligibility for Long Acting Reversible Contraceptive methods, choosing appropriate methods for complex patients with comorbidities, new methods of pain control and of uterine evacuation during all stages of pregnancy.

Finally, focus on family planning teaching has led to innovative methods of student teaching, such as so called ‘Papaya’ and ‘Values Clarification’ workshops.

Discussion: Post graduate education in family planning in the US outlines essential steps for the successful integration of such training. It meets the goals of medical education reform and educational objectives where the learners are taught to focus their practice on rapidly changing evidence, develop clinical skills and learn about professionalism through innovative approaches. Integration of family planning education enhances physician knowledge, patient care, encourages research, public health policy and the well being of women.

FC3-13

‘Sweat a bit and try not to swear…’ – do Faculty registered trainers teach the insertion and removal of subdermal contraceptive implants in a similar fashion?

A.S. Baird

Abacus Clinics, Liverpool Community Health, Liverpool, UK

Objective: The manufacturers of Nexplanon™, the subdermal contraceptive implant (SDI), recommend a published technique for insertion and removal. Endorsed in the UK by the Faculty of Sexual & Reproductive Healthcare (the Faculty), the manufacturer's technique is also recommended for the teaching of these techniques. Further, the Faculty, medical defence organisations, many service commissioning groups and local medical committees ask doctors practising in this area to have a Letter of Competence following training by a Faculty registered trainer and completion of an e-learning programme. Trainers, however, may utilise varying techniques and we have been told this is confusing for the trainee. We have asked trainers in the UK how they insert and remove SDIs when teaching.

Method: We sent a questionnaire to all UK trainers listed on the Faculty database. In two parts, we asked firstly direct questions of the participants’ techniques for insertion and removal, concerning the discrete stages of the procedures, covering such areas as recipient and fitter's positions, marking the skin, sterile precautions, usage of anaesthetic, incisions, use of scalpel and forceps, delivery of implant, dressings, and so on. Secondly, we asked for a free text description of removal technique and whether this had changed over time. We analysed responses according to (1) answers to direct questions (numerical), and (2) analysis of free text response themes.

Results: We received 198 responses. All participants replied to the first part and 179 to the second. For answers to direct questions, considerable deviations were seen from the accepted techniques in 10 categories (detailed numerical analysis is available for presentation). In another 10 categories, responses showed a 1:1 ratio of recommended technique compared with personal deviation. In only four categories was there an almost universal adoption of the recommended technique.

In the free text response analysis, there was variation in 12 sub-categories of the removal technique. These were frequently in seminal areas such as use of anaesthetic, scalpel technique, use of and type of forceps, delivery of the device (making the distal end visible; ‘pushing’ vs ‘pulling’; removal of the fibrous capsule, for example), marking the skin and skin preparation.

Conclusion: There is a wide variation in technique from the recommended one amongst UK Faculty trainers. Adoption of a technique at variance from the manufacturer's recommendation is clearly a personal preference, but given that they are allowed more than one trainer this is potentially confusing to learners.

FC3-14

Myths and misconceptions about reversible female contraceptive methods among youth through an exploratory study in Karachi Pakistan

N. Nishtar

Aga Khan University Pakistan, Karachi, Pakistan

Background: In Pakistan, low contraceptive prevalence rate (CPR) results in increased unwanted pregnancies and the picture is gloomier for youth where CPR is almost half of the national figure. Another aspect of low use of contraceptives is its relation with unwanted pregnancies ending up in unsafe abortions, morbidities and mortalities. Family planning could be one of the interventions helping in saving women's lives through proper spacing between the children and in this manner improving the quality of health of families. Myths and misconceptions are prevalent culturally in societies and as people travel they are transferred globally, therefore it is important to study them so as to come up with reasonable explanations to address them.

Objectives: To explore the perceptions regarding myths and misperceptions about reversible female contraceptive methods among married youth aged 18 to 24 years in Karachi, Pakistan.

Methods: Qualitative exploratory study design was adopted and eight focus group discussions, four each with married male and female youth were conducted until point of saturation. Content analysis was conducted and meaning units were identified, these were condensed, coding done and categories were made and themes were derived. Trustworthiness was ensured during data collection and analysis phases.

Results: The study demonstrated that use of family planning methods amongst married youth was quite low. In addition to the misperceptions about family planning in general, the main reasons identified for poor contraceptive use was myths and misperceptions about female contraceptive methods among youth. Main categories identified were general, side effects related, knowledge about the use of contraceptives related, sociocultural and religious myths and misconceptions about the use of reversible female contraceptive methods. The foremost myth was that most of the female contraceptive methods cause sterility. Most of the myths were against intra-uterine contraceptive device (IUCD): that it travels to the heart and brain. Furthermore participants perceived that hormonal contraceptives cause dryness of the ovaries. Some of the participants believed that contraceptive pills could be taken by males also. Participants believed that pill use is associated with blood pressure, heart problems and cancer of the breast and uterus in females.

Conclusion: The potential reasons behind low use of family planning methods could be myths and misperceptions about female contraceptive methods in our study area. Important policy implications are: educating girls about the importance of using family planning methods through mass media and peer leaders and training of family planning service providers to provide counselling for young people to address these myths and misperceptions amongst them.

FC3-15

Are we underestimating the value of postnatal advice?

R. Dassanayake Aratchige¹, H. Ribbans², T. Dwivedi²

¹University of Manchester, Manchester, UK, ²East Lancashire Hospital NHS Trust, East Lancashire, UK

Objective: Unwanted pregnancies resulting in abortions within 6 months of delivery may indicate birth spacing being too close, which could possibly be related to the level of contraceptive services provided. It is stated in the national guidelines that contraception should be discussed with all women within one week of delivery. Thus, the objective of this audit was to determine any documented postnatal contraceptive advice given to women who had an abortion within 6 months of delivery.

Method: This audit was carried out retrospectively and we identified women who delivered between October 2010 and November 2011 and had an abortion, at the same hospital within six months of delivery. Data collected from the maternity and abortion notes included, postnatal contraceptive advice given, contraception used prior to abortion, and history of domestic violence and safeguarding issues.

Results: A total of 77 such women were identified and this accounted for 4.7% of the total abortions in 2011 and 1.2% of deliveries from October 2010 to November 2011 in the geographical area.

A total of 57 cases were analysed and 40% of the women had received postnatal advice within one week of delivery, 72% had conceived within 3 months, 46% had not used any form of contraception prior to abortion, 21% were under 20 years of age, whilst 49% were aged 20 to 24 years. In women who disclosed domestic violence and safeguarding issues, only 44% and 29% were offered postnatal contraceptive advice respectively, within one week of delivery.

Conclusions: More emphasis on contraceptive advice for postnatal women is needed. With regards to the use of contraception, extra attention should be given for postnatal women with adverse social factors such as disclosed domestic violence and safeguarding issues.

The results of this audit have been presented at a multidisciplinary audit meeting at the hospital and have been circulated among the midwifery staff. A new section on contraception has now been included in the patient's postnatal notes.

FC3-16

‘Hands off our wombs’: An examination of New Zealand media coverage of the announcement of free long-acting contraception for welfare beneficiaries

J. Lucke

The University of Queensland, Brisbane, Queensland, Australia

Objective: A broad package of welfare reforms was announced by the New Zealand government on 7 May 2012 including the provision of free long-acting reversible methods of contraception to female welfare beneficiaries. Although the provision of access to contraception was not the main focus of the welfare reforms it was the element that attracted most public comment. This paper presents an analysis of the main themes that were evident in the New Zealand media coverage of the policy announcement.

Method: A search of the Factiva database identified 84 separate media articles: 18 articles, 37 letters or comments and 29 op-ed pieces. Most (n = 38) were published in the first 3 days after the announcement (8–10 May 2012), 31 appeared up to one week after the announcement (11–14 May 2012) and 26 were from later coverage with most articles appearing before the end of May. The text of the articles was analysed in NVivo using thematic coding. Three iterations of coding were conducted: (1) The text was coded into broad themes, (2) subthemes were created and refinements made to the coding, and (3) The description of nodes was clarified. An independent coder examined the final coding structure and differences were resolved after discussion between the two coders.

Results: Six main themes were identified: (1) autonomy was the most common theme highlighting the importance of individual responsibility and choice, or alternatively concern about the potential for coercion in contraceptive choices, (2) access was also a common theme, raising issues of the cost of long-acting methods of contraception, and the need for better access to contraception, (3) disadvantage was an important theme, though somewhat tangential to the debate about access to contraception, covering issues such as the cycle of disadvantage, and the importance of taking responsibility for children, (4) many articles focused on the stigma attached to specific groups such as women, beneficiaries or young people, (5) reproductive control, such as the consequences of unintended pregnancy or contraceptive failure, and (6) Collective control, involving the state control of reproduction were important themes.

Conclusions: The announcement of free access to long-acting methods of contraception for welfare beneficiaries sparked a flurry of media coverage in New Zealand. This analysis of media content showed that public funding of contraception remains a controversial issue in New Zealand eliciting a wide diversity of public and media opinions.

FC3-17

Ukraine: A public-private partnership (2006–2011) to improve access to and availability of affordable family planning services and supplies at the primary care and community levels

T. Rastrigina¹, N. Salo²

¹United States Agency for International Development, Kiev, Ukraine, ²JSI, Research and Training Institute, Inc., Kiev, Ukraine

Objective: To implement a public private partnership to mobilise resources for increasing access to and use of modern contraceptives in Ukraine.

Design: An innovative Public-Private Partnership (PPP) was used to bring together the USAID supported Together for Health project (TfH), the Ministry of Health of Ukraine (MOH), and seven private sector partners (PSPs).

This PPP aimed at reducing the abortion rate by increasing the use of family planning (FP) services and modern contraceptives through three main activities: strengthening knowledge and skills of service providers; improving awareness of population; and increasing local government's commitment.

The TfH and MOH provided in-service and post-graduate trainings for FP providers and pharmacists on modern counselling and availability of affordable contraceptives. PSPs supported clinical follow-up with evidence-based information through roundtables answering health providers’ concerns on contraception. Roundtable topics were developed by medical academic leaders. Behaviour change communication events to dispel myths on contraception were organised by the TfH and PSPs at public places and universities. The MOH and regional health departments were encouraged to adopt key regulations for improving the quality of care and to procure FP supplies. USAID donated free contraceptives that, similarly with the GOU procured FP supplies, were distributed to the most vulnerable groups.

Results: Participating facilities located in 15 regions covering 65% of the population were monitored to assess changes in providers and clients’ attitudes and contraceptive availability. In addition to the available USAID $12 million of funding for TfH, the PPP mobilised about $4 million from PSPs and MOH. The project's baseline (2006–2007) and endline (2009–2010) assessments in nine regions showed that the proportion of clients (N ≈ 3000) and providers (N ≈ 500) with positive attitudes increased by 10% and 8% respectively, and percentage of health facilities (N ≈ 200) with free contraceptives available to clients increased from 28% to 60%. The 2006 to 2008 follow-up surveys of 428 pharmacies in two regions showed that availability of selected mid-priced hormonal contraceptives grew by 17%. Finally, 361,000 new couples reported using free supplies.

Conclusion: In a middle-income country like Ukraine, private and public sector resources can be ‘mixed’ to improve quality of FP services and bring correct information to a wider audience. The Ukraine example can serve as a framework for other low- and middle-income countries interested in improving FP services and access to affordable contraceptive methods. These countries can consider using the key PPP approaches including identifying interests of partners, appropriate activities and ways to monitor the PPP effectiveness.

FC3-18

Use of pornography, sexual experiences and health among male high school students in Sweden

M. Mattebo¹, T. Tydén¹, E. Häggström-Nordin², M. Larsson¹

¹Uppsala University, Uppsala, Sweden, ²Mälardalen University, Västerås, Sweden

Objectives: The objective was to describe patterns of pornography use among male adolescents and to investigate differences between frequent, average and non-frequent users of pornography with respect to sexual experiences and health.

Method: This is a cross sectional survey among 53 randomly selected classes in 13 senior high schools in two cities. Female and male students were asked to answer a class-room questionnaire. The present study reports the findings among the male students and 477 out of 485 students participated in our study. The questionnaire consisted of 64 multiple-choice questions on demography, physical and psychological health, life styles, attitudes towards gender equality, use of pornography and sexual experiences.

Results: Almost all men, 96% (n = 453), had watched pornography and of these 10% (n = 47) were defined as frequent users of pornography (at least once a day), 63% (n = 292) as average users (every week/a few times a month) and 27% (n = 126) as non-frequent users (a couple of times a year/more seldom than once a year/never). Frequent users, compared to average and non frequent users, had more sexual experiences, such as one night stands (45%; 32%; 25%) and oral sex (56%; 49%; 38%). Frequent users were three times more likely to constantly think about sex (OR 3.54, CI 1.12–11.1) and claimed pornography to influence their own sex life to a higher extent compared to average users and non-frequent users (30%; 10%; 2%). Obesity was twice as common among frequent users (OR 1.91, CI 1.12–3.26) and they reported peer relationship problems to a higher extent (38%; 22%; 21%). No other differences in self-reported health were found between the groups.

Conclusions: Frequent users reported sexual experiences to a higher extent than average and non-frequent users did. Obesity was twice as common among frequent users, but they rated their physical health as good as their peers. More studies in different settings and with longitudinal designs are needed to confirm this finding.

FC3-19

Thrombotic diseases in users of estradiol/dienogest oral contraceptives: A historical national follow-up study 2009–2011

Ø. Lidegaard, C.W. Skovlund, L.H. Nielsen

Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

Objectives: To assess the influence of estradiol/dienogest oral contraceptives on the risk of developing venous and arterial thrombotic diseases.

Methods: In a historical national cohort study, all Danish non-pregnant women aged 15 to 49 years old, free of previous thrombotic disease or cancer, were followed from January 2009 through December 2011 in four national registries for use of hormonal contraception and a first time venous or arterial thrombotic event. Venous thrombosis was confirmed with anticoagulation therapy after the diagnosis. Risk estimates were calculated by Poisson regression. Included confounders were age, education, smoking, hypertension, diabetes, hyperlipidaemia, and body mass index.

Results: Analyses are ongoing. These first global results on the influence of oral contraceptives with natural estrogen and dienogest will be presented at the conference. Relative risk estimates will be calculated with non-users and with users of oral contraceptives with levonorgestrel as reference groups.

Conclusions: To be presented.

FC4-20

Comparison of bleeding patterns between continuous twelve month use of a contraceptive vaginal ring and a low dose pill in a menstrually-signalled regimen

E. Weisberg

FPNSW, University of Sydney, Sydney, NSW, Australia

Objectives: Extended use pill cycles have varied from 42 to 168 days but there are no reports of a 12 months continuous menstrually-signalled regimen or a comparative study between a low dose pill and a vaginal ring. The primary aim of the study was to compare bleeding patterns of two contraceptive regimens. A secondary aim was to evaluate if a continuous regimen affects risk parameters like weight, blood pressure or plasma lipids.

Design and methods: A total of 132 women were randomised to continuous use of a vaginal ring (CVR) (15 μg ethinyl oestradiol/150 μg etonogestrel) or a low-dose pill (20 μg ethinyl oestradiol and 150 μg levonorgestrel) for 360 days. A menstrually-signalled regimen was used with four days cessation of treatment when breakthrough bleeding occurs. Bleeding and spotting days, days of ring or pill use and menstrual symptomatology were recorded in a menstrual diary. The main endpoint was the total number of bleeding/spotting days for each method over four 90-day reference periods (RP). Detailed analysis of bleeding patterns according to WHO criteria was also carried out. Blood samples were taken at the first and last study visit.

Results: There was a reduction in the mean number of bleeding/spotting days from RP1 (CVR 14.2 ± 10; pill 16.6 ± 10.9) to RP4 (CVR 8.8 ± 9.6: Pill 8.8 ± 9.1). The two methods did not differ with regard to the mean number of total bleeding/spotting days in any RP. The bleeding response was idiosyncratic with eight CVR and two pill users, experiencing amenorrhoea or infrequent bleeding throughout the study. Amenorrhoea was much more frequent in RP4 (six in RP1 vs. 23 in RP4) and was seen more frequently in CVR users. Compliance with four day hormone withdrawal if bleeding persisted was poor. No significant changes in mean weight, blood pressure, or lipids were observed.

Conclusion: With this menstrually-signalled regimen of continuous use of a contraceptive pill or CVR the number of bleeding days dropped significantly from RFP1 to RFP4 and the number of women with amenorrhoea rose. However, the unpredictability of the bleeding pattern should be addressed during counselling. The continuous regimen does not induce changes in blood pressure or plasma lipid levels with either method.

FC4-21

European Consortium for Emergency Contraception: Working towards equitable access for women in Europe

C. Puig¹, C. Moreau², S. Cameron³, A. Glasier³, K. Gemzell Danielsson⁴

¹European Consortium for Emergency Contraception, Barcelona, Spain,²Johns Hopkins University, Baltimore, USA,³University of Edinburgh, Edinburgh, UK,⁴Karolinska Institute, Stockholm, Sweden

Objectives and background: Emergency contraception (EC) can reduce women's risk of becoming pregnant after unprotected intercourse. Levonorgestrel only EC pills have been available in most European countries for 10 years or more, but today, access varies significantly from country to country. In Portugal and France, EC has been available behind the counter (from pharmacists without a prescription) for more than a decade, while in countries like Germany, a prescription for EC is still mandatory. The diversity in service delivery modalities, as well as inconsistent protocols and clinical guidelines for EC use, leads to inequalities in access to reliable EC options for women. The introduction of new generations of EC pills (such as ulipristal acetate) as well as the promotion of IUDs for EC, provides exciting opportunities to expand access to EC for women in Europe.

Methods: Data on accessibility and use of EC in Europe is scarce. Sales data were collected and surveys were sent to key informants throughout Europe.

Results: These combined data suggest that EC is more widely used in countries with non prescription access. Norway, Sweden and France have the highest estimated proportion of users: 14%, 12% and 10% respectively (estimated as number of EC units sold per year divided per number of women aged 15–49 years). Italy, Hungary, Germany, Poland and the Czech Republic, show the lowest records of use (below 3%). Use in other European Union states ranges from 4 to 9%.

Conclusion: Our data confirm that access to EC is highly uneven in Europe. In light of this situation, the European Consortium for Emergency Contraception (EC EC) was launched in 2012. A key proposed activity for 2013 will be the adaptation of the newly released Medical and Service Delivery Guidelines on EC, developed by the International Consortium for EC and endorsed by the International Federation of Gynecology and Obstetrics (FIGO). Europeans interested in furthering access to EC through research, policy guidance, and networking are encouraged to join our network.

FC4-22

The efficacy, safety, and acceptability of medical abortion provided by nurse midwives or physicians – a randomized controlled equivalence trial

H. Kopp Kallner, K. Gemzell Danielsson, R. Gomperts

Karolinska Institutet, Stockholm, Sweden

Objectives: Medical abortion is highly acceptable to women. However access to abortion care may be limited by the unwillingness of physicians to be involved in abortion care or by a shortage of physicians. This randomised controlled equivalence trial aimed to assess efficacy, safety and acceptability of midlevel provision of medical abortion and perscription of contraceptives by midlevel providers in a clinical high resource setting.

Method: A total of 1180 women eligible for inclusion were recruited and randomised, without any prior examination, to counselling, examination including ultrasound, and treatment by either nurse midwife or gynaecologist. Mifepristone 200 mg was given orally and patients were given a choice of administration of 800 mcg vaginal misoprostol at home or in the clinic according to preference. A follow-up visit was performed after three weeks. Efficacy, safety, and acceptability were evaluated and the prescribed method of contraception was studied through patient records and questionnaires.

Results: The provision of medical abortion by midlevel providers is as effective and safe as that provided by physicians. The risk difference for efficacy was 1.6% with a confidence interval of 0.2–3.0% (p = 0.027) which was within the − 5% to + 5% set margin of equivalence. There were no significant differences in any safety parameters. Women examined and counselled by a midwife were significantly more likely (p < 0.001) to prefer seeing a midwife for the consultation were they to have another medical abortion in the future. Midwives were sigificantly more likely to prescribe LARCs compared to physicians (p = 0.004).

Conclusions: These findings show that midlevel provision in a high resource setting where ultrasound is part of the protocol is effective and can be safely implemented with high acceptability among women. Midlevel provision of medical abortion can increase access to medical abortion where the number of physicians is limited or where physicians are unwilling to perform abortions. In addition midwives are significantly more likely to prescribe LARC to women seeking medical abortion. This may have an impact on repeat abortions.

FC4-23

How to implement sexuality education programmes effectively in different cultural contexts?

S. van der Doef

Rutgers WPF, Utrecht, The Netherlands

Objectives: A specific protocol is developed to implement an existing sexuality education programme for young people in different cultural contexts, in such a way that the sexuality education programme is accepted, sustainable, gives increased ownership and will be advocated by the users.

Method: The implementation protocol is based on the method of Intervention Mapping. The protocol is adapted to be used as a step-wise implementation protocol in different cultures. Essential is the participation of the young people themselves in the adaptation of the programme to their own context.

Results: The implementation protocol makes use of eight steps, based on the steps of Intervention Mapping:

(1) Involvement

(2) Situation analysis/needs assessment

(3) Objectives

(4) Adaptation

(5) Pilot

(6) Finalising the programme

(7) Launch/implementation

(8) Monitoring and evaluation

In the presentation all steps will be explained and illustrated by several cases in different cultures (Uganda, Ethiopia, Bangladesh and Indonesia).

Conclusions: The implementation method has been used up until now in eight different countries with the same sexuality education programme called: The World Starts With Me. This programme is adapted not only to different countries and cultures but also for different age-groups and settings: from young children in Kindergarten, pupils in Primary Schools to students in Secondary schools and Universities or Teacher Training Colleges, and also for boys in prison and juvenile institutions and for young HIV positives. What we see is that each step is important to take and has value in the implementation process. By involving the target group (young people, students, teachers and parents) the adapted programme will be based on the needs of the young people and accepted by the community. When implementers follow the steps carefully, ownership will increase and stakeholders and young people will become the best advocates of the programme.

FC4-24

A study of the contraceptive use in Cameroon (1991–2004): We are coming from far

A.P. Yotchou Tzudjom, N.E.N. Jeanne, S. Alexis

Cefap-Ladies Circle, Yaounde Centre, Cameroon

Background: In every country, contraceptive behaviour has important implications for fertility and the prevalence of sexually transmitted diseases (STDs). There has been relatively little attention to the dynamic of contraceptive practices in Africa, however, particularly how patterns of method use may have changed during a period.

Also, despite the fact that choosing a contraceptive method is often a decision made by couples, little is known about the dynamic of perceptions of men and women, the characteristics of various method types, and in the importance that they attach to those characteristics when choosing a contraceptive method. Numerous differences between them may have an important influence on how couples make their method choices.

Methods: Data on contraceptive use in Cameroon were collected from 5315 women in the 1991 DHS Survey, and from 3220 women and 3449 men in the 1998 and 2004 DHS Surveys.

Results: Among Cameroonian women aged 15 to 49, current contraceptive use declined from 69 to 60% between 1984 and 1995. Pill use dropped from 19 to 17%, and IUD use declined from 6 to 3%. However, during the same period, condom use increased from 6 to 10%; tubal ligation declined from 24 to 17%, while vasectomy increased. In addition, the proportion of women sterilised for reasons other than contraception rose between 1984 and 1995. Men were less likely to rely on sterilisation than women (31% vs. 40%). Men reported higher levels of condom use (22%), but lower levels of pill use among their partners (9%), than did women (10% and 17%, respectively).

Conclusions: Contraceptive behaviour in Cameroon is unique: The stability in contraceptive use over the last decade has left Cameroon's overall contraceptive prevalence among the lowest in Africa. These changes in contraceptive behaviour complicate efforts to plan for social and health needs, particularly policy decisions focusing on reducing infections with STDs. These changes in contraceptive behaviour complicate efforts to plan for social and health needs, particularly policy decisions focusing on reducing infections with STDs.

Finally men and women have somewhat different priorities when choosing a contraceptive method. Despite many similarities between women and men in their perceptions about the characteristics of each method type, numerous differences between them may have an important influence on how couples make their method choices.

FC4-25

Contraceptive use and unintended pregnancy among 18–23-year-old women in Australia: The first findings of the CUPID study

D. Herbert¹, M. Harris², D. Loxton², J. Lucke³

¹Queensland University of Technology, Brisbane, Queensland, Australia, ²University of Newcastle, Newcastle, New South Wales, Australia, ³The University of Queensland, Brisbane, Queensland, Australia

Objectives: Little is known about young adult women's experience of unintended pregnancy in Australia, nor the extent to which ineffective contraceptive use or contraceptive failure may lead to young women becoming pregnant. The CUPID study is the first in Australia to examine young adult Australian women's patterns of contraceptive use, their experience of unintended pregnancy, and their use (or not) of contraception at the time of conception.

Methods: Australian women aged 18 to 23 years completed an online survey about contraceptive use and experience of unintended pregnancy. They were recruited through a range of methods including advertising on Facebook, and snowball sampling. Sample representativeness was established through comparison with Census data.

Results: Of the 511 respondents, 403 women reported that they had ever had sex and were not currently pregnant. Among these women, the pill was the most common method of contraception used on the most recent occasion, used alone (30%) or with condoms (21%). Condoms (alone or with another method other than the pill) were used by a further 17%, and long-acting contraceptive methods by a further 16%. Other methods such as natural methods or partner vasectomy were used by 16%. The withdrawal method was surprisingly common and was mentioned by 15% of the women overall, usually in combination with another method. There were 63 women who had been pregnant, including five who were pregnant at the time of the survey, and of these 55 (87%) had become pregnant by accident. Of these 55 women, 69% reported using a range of contraception methods when they became pregnant by accident: Pill only (29%) and in combination with condoms (3%) and withdrawal (5%); condoms only (18%) and in combination with withdrawal (16%); emergency contraceptive pill only (3%) and in combination with withdrawal (3%) and withdrawal only (24%).

Conclusions: This study highlighted the use of less effective methods of contraception among young Australian women. The withdrawal method was commonly used, often in combination with other methods, particularly before an unintended pregnancy. Among the women who had been pregnant, most reported that their pregnancy had been unintended. A third of the young women who had experienced an unintended pregnancy were using the withdrawal method. Further research is needed about the place of the withdrawal method in the contraceptive practices of young women.

FC4-26

Attitude of women towards legislation changes in abortions in Russia

L. Erofeeva

Russian Association for Population and Development, Moscow, Russia

Background: Intensification of the public movement against abortions became the reason for changes in the Russian legislation on abortions (Federal law ‘Basics of legislation on health protection of the citizens of the Russian Federation’ №323, adopted on 21 November 2011).

Aims: To find out the opinion of Russian women towards the legislative initiatives towards abortions.

Methods: The research was conducted for RAPD in 2011 in seven Federal districts of Russia among the residents of 34 populated areas, including 10 administrative structures with population under 100,000, eight cities of 100 to 499,000 residents, seven cities of 500 to 999,000 residents and nine cities with 1,000,000 residents.

Results and discussion: The majority of Russian women admit the need to plan their childbirth (77%), however 23% of them think that family planning is an optional issue. As a rule, those respondents are over 45 y.o. (18%), undereducated (18%) with unexpected child occurrence (17%). Those women who have no more than two underage children are more inclined to consider that family planning is a necessary thing (82%). There are more of those among parents with many children (large families) who do not see any sense in the issue at all (18%).

A total of 51% and 41% of women respectively disagree with the initiatives to have a ban on abortions or to an obligatory charge for this service, 38 and 43% respondents respectively agreed with the necessity to introduce the waiting period of seven or two days, whilst 46% and 39% disagreed. A total of 41% of women supported the idea of obligatory psychological consulting, 73% of women would consult a certificated psychologist and only 16% would consult an uncertified orthodox psychologist. A total of 63% considered incorrect the mandatory listening to the foetus heartbeat and the foetus ultrasound pictures before abortion, whilst 91% of women considered it important to be mandatorily informed on the details of medical intervention, and 75% expressed their opinion on having a written consent from an underage girl's parents for an abortion. Nearly half (47%) agreed with the introduction of mandatory written consent from the spouse but 43% disagreed with that.

Conclusion: The research identified the diverse opinion of women on the issues of legislative initiatives for restriction of their rights for abortions.

FC4-27

Usage patterns and accessibility of Emergency Contraception other-the-counter versus prescription-only

E. Bumbul¹, M. Starek¹, B. Pietrzak³, I. Szymusik³, M. Wielgos³, Z. Bumbuliene²

¹Medical University of Warsaw, Warsaw, Poland, ²Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania, ³1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland

Objectives: The aim of our study was to compare the usage, knowledge and accessibility of EC when available over-the-counter (OTC) with prescription-only availability of EC. Our hypothesis was that EC when available OTC is taken earlier, the level of knowledge about EC increases with advertising, the availability of EC in Poland is limited due to prescription requirement and Conscience Clause.

Methods: Original questionnaires were created and adjusted to the countries. The Lithuanian questionnaire was approved by the Lithuanian Bioethics Committee. There is no such requirement in Poland. We used the Polish group as a prescription-only model, whereas the Lithuanian group was chosen for an OTC model. After the validation, 1000 paper-and-pencil questionnaires were given out among Polish and 650 among Lithuanian students. The response rate was 83% in Poland and 89% in Lithuania. SAS 9.3 software was used for statistical analysis. Only complete questionnaires filled by 16 to 35-year-old high school, college or university students were included.

Results: Polish and Lithuanian groups did not differ significantly in age, age at the first intercourse, or the length of sexual activity and 29% of Poles and 33% of Lithuanians had a history of EC usage. In case of emergency, the majority of Poles went to a doctor, in 89% of cases to a gynaecologist, and 74% did not know that EC can be prescribed by any specialist. Only 13.4% of Lithuanians sought a doctor's advice. A total of 41.8% of Poles and 79.3% of Lithuanians were administered EC pills within 12 h (p < 0.001), and 93.5% of Poles and 99.3% of Lithuanians within 72 h, whilst 12.6% of Poles had an obstacle with obtaining the prescription.

Level of knowledge about EC was significantly higher in Lithuania (p < 0.001) and was gained mainly from the Internet and other media. The main reasons for EC administration was regular contraception failure 66.9% in Poland vs. 64.3% in Lithuania. No contraception was used only in a quarter of cases. Once only EC was used by 70.2% vs. 69.6% respondents, 5 times or more by 1.8% vs. 0.7% (Poland, Lithuania, respectively). According to 63.7% of Poles vs. 16.1% of Lithuanians EC should be a prescription-only drug.

Conclusions: The accessibility and knowledge about EC should be improved in Poland. The delay in administration of EC due to prescription requirement and overuse of Caution Clause is inacceptable. The discussion in Poland about introducing EC pills OTC is necessary.

FC4-28

Male views on female condoms results from a qualitative study in Zimbabwe, Cameroon and Nigeria

W. Koster¹, M. Groot Bruinderink¹, W. Janssens²

¹Amsterdam Institute for International Development, Amsterdam, The Netherlands, ²VU University, Amsterdam, The Netherlands

Objectives: Female condoms (FCs) have been positioned as an effective, female-initiated double protection method. However, studies among women in Sub-Saharan Africa show that uptake is low. Although FCs are promoted as a tool for women's empowerment, decision-making power on protection is often male focused. There is a lack of evidence on perceptions of FCs from a male point of view. Our applied study addresses this gap, aiming to elicit and contextualise male views on FC.

Methods: Data collection (2011) took place in (semi-)urban areas in Zimbabwe, Cameroon and Nigeria to enable a comparison in contexts with varying HIV prevalence and contraceptive use rates. We stratified 52 focus group discussions (FGDs) by sex, marital status, and frequency of FC use. Of 488 participants, 350 were men. Frequent male users were deliberately oversampled. Main FGD themes were: FC acceptability by type of sex partner, motivations for first and regular use, patterns of use. Additional data were derived from eight in-depth interviews with male frequent users. Manual content analysis was performed by theme; group and country differences were explored.

Results: Generally, men considered initiation of FCs by any sex partner unacceptable. Main reasons for first time use: curiosity about sexual pleasure and difference with male condoms (Zimbabwe, Cameroon); trying a contraceptive without side-effects (Nigeria). First-time experiences were decisive for continued use. Men continued FC use because of: sexual pleasure, effectiveness, no side-effects. Men used FCs for family planning (FP) with spouses and/or stable partners – where male condoms were undesirable because of associations with infidelity/disease. Nigerian and Zimbabwean men rarely used FCs with casual partners and sex workers as they fear misuse, and allocate short time for sex. Cameroonian men used FCs with casual partners for HIV/STI prevention.

Conclusions: Findings concur with local normative gender relations: men make decisions and husbands control wives’ sexuality/fertility. With male users satisfied with FCs, increased targeting of men will provide opportunities to enhance uptake and contribute to reduced HIV transmission and improved family planning practices. Especially for married men, FCs could be promoted for FP – with additional benefit of STI/HIV protection. Given the current levels of awareness and acceptance, FCs do not appear to be an effective vehicle that can empower women to advance their strategic gender interests. However, FC use may be of practical gender interest to the extent that it can increase the overall rate of protected sex acts.

FC5-29

Is teenage pregnancy an obstetric risk in a welfare society? A population-based register study in Finland, 2006–2011

S. Leppälahti¹, M. Gissler², M. Mentula¹, O. Heikinheimo¹

¹Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland, ²National Institute for Health and Welfare, Helsinki, Finland

Objectives: To investigate whether teenagers are at a risk for adverse obstetric outcomes in a country with a low rate of teenage births and equal, high-quality prenatal care.

Design and methods: This nationwide retrospective register study included all singleton deliveries in Finland between 2006 and 2011 among nulliparous women below 20 years of age (13 to 15 years [n = 89], 16 to 17 years [n = 1279], 18 to 19 years [n = 6267]) and in controls of 25 to 29 years of age (n = 53488). The adjusted odds ratios (Adj. OR) and their 95% confidence intervals (CIs) were derived through binary logistic regression models with adjustment for potential confounding factors.

Results: Pregnant teenagers were significantly (p < 0.001) more likely than controls to live in a rural area (16.1% vs. 11.9%), smoke (37.6% vs. 7.1%) and be diagnosed with misuse of alcohol or drugs (1.1% vs. 0.2%).

All teenage subgroups had a good mean number of prenatal visits (14.6 among 13 to 15 y, 16.1 among 16 to 17 y and 16.5 among 18 to 19-year-olds vs. 16.5 among controls). However, teenagers started their prenatal care at significantly later gestational weeks (18.9 [mean] among 13 to 15 y, 12.6 among 16 to 17 y and 10.3 among 18 to 19-year-olds vs. 9.0 among controls). Also, all teenagers were more likely to have significantly lower attendance with 0 to 5 visits (2.6% vs. 1.1%).

Teenagers were associated with several maternal complications during pregnancy, e.g., anaemia (Adj. OR 1.9 [95% CI 1.7–2.2]) and proteinuria (Adj. OR 1.6 [1.3–1.8]), with risks increasing by descending age. An increased risk for pre-eclampsia was found among 13 to 15-year-olds (Adj. OR 2.9 [1.2–6.8]). Higher risks for cystitis and pyelonephritis were also seen (13–19 years: Adj. OR 2.5 [1.6–4.1] and 5.8 [3.6–9.4], respectively).

All teenage mothers were more likely than controls to deliver vaginally (Adj. OR 1.6 [1.5–1.8]) and had lower risks for Caesarean section (Adj. OR 0.6 [0.5–0.6]) and operative vaginal delivery (Adj. OR 0.6 [0.6–0.7]). Neither were risks for other complications during delivery found.

Parturients aged 13 to 15 y were at a higher risk for preterm delivery (OR: 2.7 [1.4–5.0]). Teenagers were also more likely to deliver small-for-gestational-age (SGA) newborns (OR 1.4 [1.2–1.6]). These risks, however, became statistically insignificant after adjustment for confounding factors.

Conclusions: Pregnant teenagers tend to be socioeconomically disadvantaged compared to older mothers and face higher risks for various complications during pregnancy. Maternal problems during delivery were rare, but neonatal risks were found. Overall, special attention should be paid to the youngest teenagers, who seem to face the highest risks.

FC5-30

Unplanned pregnancy and contraception choice in women living with HIV: A 12-year case review in a large urban centre

D. Brawley, P. Anderson, F. Fargie

Brownlee Centre, Gartnavel General Hospital and Sandyford Sexual health Services, Glasgow, UK

Objectives: The sexual and reproductive health needs of women living with HIV (WLWH) are complex. In addition to drug interactions and the need for barrier methods to prevent transmission, WLWH often have co-existing vulnerabilities. A case note review was performed in an HIV centre with SRH input to review unplanned pregnancies, partner documentation and contraception pre- and postpartum.

Methods: A retrospect case note review of all pregnancies was performed from 1 January 2000 until 1 January 2012. For each pregnancy data was collected regarding baseline demographics, unintended conception, pre-pregnancy contraception, partner documentation, pregnancy outcome and postpartum contraception.

Results: There were 156 pregnancies in 117 women of whom 74% were African, 24% British and 1% Eastern European. The mean age at pregnancy was 30 years. Forty-one pregnancies were in women diagnosed HIV positive antenatally and 115 pregnancies followed HIV diagnosis. Of the 41 women diagnosed antenatally, 78% of pregnancies were planned and 86% had a documented partner. Forty pregnancies resulted in a live birth and one was terminated. Postnatal contraception is shown below.

• 44% long acting reversible contraception (LARC)

• 17% oral contraception

• 15% condoms

• 24% declined contraception

Among nine women with unplanned pregnancy, postnatal LARC was initiated in six and three declined contraception.

Of the 115 pregnancies following HIV diagnosis, 48% were unplanned and 2% followed sexual assault. In 23% of pregnancies no partner had been disclosed to the HIV clinic. Of the unintended pregnancies pre-conception contraception is shown below.

• 6% discontinued LARC

• 20% condoms

• 2% oral contraception

• 72% declined contraception

Eighty-seven (76%) pregnancies were continued. Postnatal contraception is shown below and did not differ significantly if the pregnancy was unintended.

• 50% LARC

• 14% barrier methods

• 32% declined contraception

Twenty-eight (24%) pregnancies were terminated and subsequent contraception was LARC in 46%, barrier methods in 18%, oral contraception in 4% and no method in 32%.

Conclusion: These findings suggest there remain significant barriers to contraception for WLWH in our setting, despite excellent and free access to LARC. This is compounded by difficulties in acknowledging partners to healthcare providers which is intrinsically linked to the vulnerabilities faced by WLWH. In order to address these complex needs, multi-faceted strategies are required not only to address access but also to empower WLWH in their wider life. Only when vulnerabilities are tackled will WLWH be able to take ownership of their sexual and reproductive health.

FC5-31

Cycle control and bleeding patterns for a new contraceptive vaginal ring delivering 150 μg Nestorone^® and 15 μg Ethinyl Estradiol: Results from a multi-centre, multi-national open label Phase 3 clinical trial

E. Hoskin¹, K. Roberts¹, M. Cooney¹, R. Sitruk-Ware¹, D. Apter², L. Bahamondes³, E. Banks⁴, G. Bártfai⁵, V. Brache⁶, H. Croxatto⁷, P. Darney⁸, I. Frasier⁹, K. Gemzell Danielsson¹⁰, M. Gilliam¹¹, M. Miranda⁷, D. Mishell¹², D. Portman¹³, J. Steinauer⁸, E. Weisberg⁹, R. Merkatz¹

¹Population Council, New York, NY, USA, ²Family Federation of Finland, Helsinki, Finland, ³University of Campinas, Campinas, Brazil, ⁴Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA, ⁵Albert Szent-Györgyi Medical University, Szeged, Hungary, ⁶Profamilia, Santo Domingo, Dominican Republic, ⁷Instituto Chileno de Medicina Reproductiva, Santiago, Chile, ⁸San Francisco General Hospital, UCSF, San Francisco, CA, USA, ⁹FPA Health, Sydney, Australia, ¹⁰Karolinska Hospital, Stockholm, Sweden, ¹¹University of Chicago Hospitals, Chicago, IL, USA, ¹²University of Southern California Medical Center, Los Angeles, CA, USA, ¹³Columbus Center for Women’s Health Research, Columbus, OH, USA

Objectives: The Nestorone^®/Ethinyl Estradiol Contraceptive Vaginal Ring (NES/EE 150/15 CVR) is a novel, user-controlled, long-acting contraceptive method that can be reused for up to one year. It is inserted into the vagina by the woman, left in place for 21 days and removed for 7 days each cycle for up to 13 cycles. It does not require refrigeration during periods of non-use. This combined hormonal contraceptive contains NES, a novel nonandrogenic progestin that has been shown to have potent antiovulatory effects at low doses. Data from the multi-centre, multinational Phase 3 trial demonstrate that it is easy to use by women with varying demographic characteristics. It holds the promise of providing an additional contraceptive choice for women, including in regions where the unmet need for contraception remains high and access to contraceptive methods is difficult.

Method: A total of 1135 healthy normally ovulating women aged 18 to 40 were enrolled and followed for one year from 12 multinational sites. Cycle control and bleeding patterns were assessed for 1054 subjects using subject diaries and self-reports.

Results: Analysis from these data demonstrated that during the ring out period when bleeding was expected (scheduled bleeding Days 22–28 for each cycle; a total of 91 days for the 13 cycles), the mean and median number of bleeding and/or spotting days per cycle remained relatively constant across all cycles. Overall, for all cycles combined in 1054 subjects, the mean and median number of scheduled bleeding and/or spotting days per cycle per subject were both 4.6 (SD = 1.4). During the ring in period, when bleeding was not expected (Days 1–21, total of 273 days), the mean number of bleeding and/or spotting days per cycle varied with no trend observed across cycles. For all cycles combined, the mean number of unscheduled bleeding and/or spotting days per cycle per subject was 0.7 (SD = 1.46) and the median was 0. The percentage of subjects who experienced amenorrea, i.e. never bled and/or spotted on scheduled bleeding days during all of their cycles was 2.0% (21/1034) whereas the percentage of subjects who never bled on scheduled bleeding days during all of their cycles was 3.5% (36/1034). The percentage of subjects who discontinued from the study due to bleeding and/or spotting issues (scheduled or unscheduled) was < 1%.

Conclusion: Overall results with this novel NES/EE CVR suggest effective cycle control and optimal bleeding patterns. Subjects rarely reported difficulties related to bleeding patterns with this CVR.

FC5-32

Awareness of contraception and sexual autonomy among youths in selected states in India

R. Ramu

International Institute for Population Sciences, Mumbai, India

Objective: To examine the awareness level of youths on contraception and their sexual autonomy in selected states of India.

Methods: The analysis was carried out based on 50,848 youths in the age group 15 to 24 years included in the youth survey, 2006 to 2007 in India. In this study bivariate analysis and multivariate logistic regression were performed to determine the awareness of contraception and sexual autonomy among youths by selected background characteristics. To define the awareness about contraception, use of condom, IUD, withdrawal and pills were used. For the analysis of sexual autonomy of women, spouse having sex without consent and forceful sexual relations was used. The analysis is carried out for different background characteristics likes place of residence, caste, level of education, wealth index of women to estimate the significant variations. Statistical package for Social Sciences (SPSS) version 20 was used to analyse the result in the study.

Results: The results of this study indicate that knowledge of contraception is relatively low in rural compared to urban areas. People with high level of education and from affluent families have higher awareness of contraception. Youths of Hindu religion (84.1%) were more aware than any other religions in India. Education of respondents and awareness of contraception were significantly related in the study. As education increased knowledge on contraception also increased. The young generation aging 15 to 19 years (47.2%) were more aware about the contraception in the study. Youths from the higher wealth quintile and with higher education are more likely to be aware about the contraception. Likewise, nearly one quarter of youths from affluent families have knowledge of contraception whereas only 13% of youths from poor backgrounds had this information. Among all states, Maharashtra (24.8) followed by Bihar (19.6) had higher awareness on contraception.

Conclusion: Youths in the 15 to 19 age group have significant awareness about contraception and certainly signifies their active sexual life. However, there is an urgent need to educate youths more about the adverse effects of active sexual life including contraception morbidities at early ages in life.

FC5-33

Risk profiling for ineffective contraceptive behaviours during adolescence: A decision tree approach to assist health care providers

R. Pires¹, J. Pereira¹, A. Araújo-Pedrosa¹, T. Bombas², L. Vicente³, M.C. Canavarro¹

¹Faculty of Psychology and Educational Sciences of the University of Coimbra; Psychological Intervention Unit of the Maternity Doctor Daniel de Matos, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, ²Obstetric Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, ³Head of Sexual, Maternal and Child Health Division, Directorate-General of Health, Lisboa, Portugal

Objectives: Although 70% of adolescent pregnancies are not intended and can be prevented through effective contraceptive behaviours, seeking family planning remains a difficult task for many adolescents. Our aim was to develop risk profiling for ineffective contraceptive behaviours in order to assist health care providers to easily screen adolescents during routine appointments; a decision tree model was built to describe the interplay between demographic, relational, and reproductive factors when predicting ineffective contraceptive behaviours. Decision trees are visual, structured, and easy-to-understand, which are requirements of health care screening. Our secondary aim was to explore the types of ineffective behaviours and adolescents’ explanations for adopting them.

Method: Data from 353 female adolescents who had been ineffective in avoiding pregnancy (IAP) and 419 nuligestas with effective contraceptive behaviours were collected through self-report questionnaires at health and educational services. The tree model was constructed using the Exhaustive CHAID algorithm.

Results: The model correctly predicted 92% of the cases in the IAP group. Education was the strongest predictor and the only significant predictor for adolescents with ≤ 7 years of education (95% of whom were IAP). For adolescents with 7 to 11 years of education, the next best predictor was boyfriend's age. About 69% of adolescents with 7 to 9 years of education and boyfriends up to one year older than themselves were IAP. For adolescents with 7 to 9 years of education and boyfriends more than one year older than themselves, the model included another predictor: urban residency (99% were IAP). About 50% of adolescents with 9 to 11 years of education and boyfriends more than seven years older were IAP. For adolescents with 9 to 11 years of education and boyfriends up to seven years older, the last predictor was 7 to 12 months of dating (54% were IAP). For adolescents with 9 to 11 years of education, boyfriends up to seven years older, and 12 to 24 months of dating, the model included another predictor: sexual initiation before 16 (44% were IAP). For adolescents with > 11 years of education, the model included only another predictor: four-plus-member families (26% were IAP). Age, ethnicity, socioeconomic status, age at menarche, and number of sexual partners were not significant predictors. Ineffective behaviours and their causes were described.

Conclusions: Our findings allow health providers to easily identify adolescents most likely to engage in ineffective contraceptive behaviours, in order to provide them with effective family planning options. Knowing the most frequent ineffective behaviours and its associated causes allows intervention to be tailored to adolescents’ preferences and needs.

FC5-34

Unwanted pregnancy and contraceptive practice in Latvia

A. Spridzane¹, A. Tula¹, N. Mosna¹, L. Lidaka², I. Viberga²

¹Riga Stradins university, Riga, Latvia, ²University of Latvia, Riga, Latvia

Introduction: Although annual national data shows continuous decline in abortion rate in Latvia (from 60 per 1000 women in reproductive age in 1991, to 18 per 1000 women in reproductive age in 2008) still – according to the World Health Organization's data, the abortion rate in Latvia is the fourth highest among all European Union countries, that constitutes 387 per 1000 live births. According to the studies in this field, low socio-economic background, poor education, insufficient knowledge in sexual and reproductive health issues, inappropriate use or disuse of contraception, or use of unsafe methods, are the main risk factors for unwanted pregnancy.

Aim: To understand the determinants of an induced abortion: socio-demographic, economic, relationship with partner, accessibility of physician, contraceptive habits and knowledge about contraception methods, and to investigate the factors influencing the decision making of abortion.

Design and methods: A cross-sectional descriptive study, questioning women attending pregnancy on-request termination in the medical institutions in Latvia during a three-month period. They will be asked to fill the semi-structured anonymous questionnaire regarding determinants of an unwanted pregnancy and the induced abortion. One open question will be provided in order to clarify the woman's own beliefs for reasons why the unintended pregnancy occurred. Data analysis will be done using the MS Excel 2007, CIA and SPSS 19 software, p value < 0.05 will be considered significant. The research has obtained the approval from Ethical committee of University of Latvia.

Results and conclusions: The distribution of questionnaires was started on 23 October 2012 and will finish on 23 April 2013 according to the study protocol. Analysis of the collected data will be done and results and conclusions will be presented at the First Global conference on contraception. At the time of submission of this abstract, the results of our study are not yet available.

FC5-35

Critical review of FP and PAFP policies and current practices of integrating PAFP into existing health service in China and worldwide

N. Xiao¹, Q. Liu², J. Xu³, Y. Che⁴, Y. Zou², X. Qian³, W. Zhang⁵, INPAC consortium⁵

¹School of Public Health & Management, Chongqing Medical University EHCRC China Effective Health Care Network, ChongQing, China, ²China National Research Institute for Family Planning China National Research Institute for Family Planning, Beijing, China, ³School of Public Health, Fudan University, Shanghai, China, ⁴Shanghai Institute of Planned Parenthood Research (SIPPR), WHO Collaboration Centre, Shanghai, China, ⁵International Centre for Reproductive Health (ICRH), WHO Collaboration Centre. Ghent University, Brussel, Belgium

Objective: Systematic review and analysis of policies in relation to FP and PAFP, the status and factors in relation to provision, utilisation and quality of FP and PAFP service in China, and practices and effects of integrating PAFP into existing health services worldwide in order to inform the design of the specific INPAC (Integrating Postabortion Family Planning Service into China’s existing abortion services in hospital setting) interventions to deliver PAFP in China.

Method: A systematic search for relevant policies and literatures was conducted. Based on a set of criteria, all the citations and full texts were screened and appraised. Valuable information was extracted. Findings of included policies and studies were reviewed and analysed using a textual narrative approach to synthesis.

Results: Altogether, 109 policy documents were included. The focus was mainly on general FP advocacy, counselling, provision and quality of care including abortion, health financing and supervision mechanism. The target population of these official documents is largely married couples. Unmarried women of reproductive age, particularly those of migrants are neglected. A total of 16 Chinese papers were reviewed to find factors in relation to provision, utilisation and quality of FP and PAFP service in China. They were client educational level, contraceptive method use, quality of FP services, the service model of PAFP, contents and timing by service providers and capacity of service providers. A total of 28 international studies were reviewed for the practice of PAFP worldwide. Efforts of integrating PAFP into existing health services included funding to the programmes, TOT training and on the job training of service provider, expansion of the range of contraceptive methods availability, improving data collection including cost analysis in a few countries, service guidelines provided to health professionals, supportive supervision at programme sites to ensure quality of care, and leadership from government to strengthen PAC/PAFP service by revising or developing new national policy. Effects of those intervention programmes included decreased abortion rates, improved modern contraceptive use, improved contraceptive acceptance, improved women's knowledge on sexual & reproductive health, and women's high satisfaction rate with receiving PAC/PAFP services.

Conclusion: China's PAFP policy is not sufficient to benefit all the population with needs. Experience from other countries may help China take into account in our future intervention programme including supportive policy environment, capacity building for service provider, continued efforts to improve the quality of PAFP service, accessibility of multiple contraceptive supplies, good record keeping, and adequate and regular supervision and monitoring.

FC5-36

Elective abortion in Portugal: A national research project aimed to understand reproductive decisions and psychological adjustment after abortion in different reproductive phases

J. Pereira, R. Pires, M.C. Canavarro

Research Line Relationships, Development & Health of the R&D Unit Institute of Cognitive Psychology, Vocational and Social Development of the University of Coimbra; Psychological Intervention Unit, Coimbra, Portugal

Objectives: The Portuguese abortion law allowing elective abortion is recent. Consequently, the research on the individual, relational, and demographic variables involved on women's decision to terminate a pregnancy and on their subsequent psychological adjustment is scarce in Portugal. Additionally, several international studies have suggested that the decision to terminate a pregnancy and the subsequent adjustment may be influenced by life circumstances, namely women's life projects and reproductive phase. Accordingly, we hypothesised that adolescents and women of advanced reproductive age that engage in elective abortion may have particular characteristics that should not be generalised from the pre-existing research using samples of women of normative reproductive age. As elective abortion rates are largely heterogeneous among different age groups and regional areas, the aim of the current project was to identify individual, relational, demographic, and reproductive profiles of women who engage in elective abortion, according to their reproductive phase and place of residence. We also aimed to analyse women's psychological adjustment immediately after abortion (assessed retrospectively) and two to four weeks later, screening for age and regional differences.

Methods: This project has a cross-sectional design. The sample is being collected at 23 healthcare services from different regional areas. The study groups consist of women that engage in elective abortion, according to their reproductive phase [adolescents (≤ 19 years); women of normative reproductive age (20 to 34 years); women of advanced reproductive age (≥ 35 years)]. The dimension of each group was established in order to be nationally representative. Individual, relational, demographic, and reproductive data, as well as women's adjustment, are being assessed through self-report measures. Specific measures of depressive symptoms (Edinburgh Post-natal Depression Scale), positive and negative feelings regarding abortion (Adjective Scales), and quality of life (EUROHIS-QOL-8) are being used.

Results: Data analysis is already under way, and specific results are already available for the adolescents group. Analyses ongoing for the other study groups will soon allow us to clarify the role of women's age on reproductive decisions and on their subsequent adjustment.

Conclusion: The final results of this project may contribute to establishing specific guidelines for family planning in different reproductive phases. They may also allow health care providers to efficiently support women during their reproductive decisions, identifying those at greater risk of psychological difficulties and providing them with specialised interventions.

FC5-37

Building a sustainable reproductive health programme that contributes to the achievement of millennium development goals by investing in family planning interventions

O. Kuzmenko¹, T. Rastrigina²

¹JSI Research & Training Institute, Inc., Kiev, Ukraine, ²United States Agency for International Development, Kiev, Ukraine

Objectives: In a pro-natalist environment the Government of Ukraine's (GOU) investments to improve family planning (FP) and Reproductive Health (RH) service provision contribute to reaching the MDG Goal 5.

Method: The USAID-supported Together for Health project (TfH) assisted key Ukrainian stakeholders to design the State Program ‘RH of the Nation until 2015’ (SPRHN), consistent with the WHO's RH Strategy. The SPRHN employs public health approaches that are new in Ukraine, such as adoption of evidence-based guidelines/protocols, public education, and procurement of preventive medicines (i.e., contraceptives and vaccines). To convince the GOU of the need for the national FP/RH investments as an integral part of SPRHN, the TfH project developed advocacy materials explaining the rationale for FP in low-fertility countries including health and financial benefits of investing in FP/RH. The project also worked with national and regional health experts representing 15 out of 27 regions to develop relevant tools to facilitate planning and budgeting processes of SPRHN. Finally, the TfH worked with the MOH to set up national and regional working groups and coordinating committees for SPRHN implementation. It encouraged transparent decision-making, accountability, and assisted in establishing a standardized monitoring system of the central and regional expenditures.

Results: From 2006 until 2011 the total SPRHN expenditures of $53.6 million were 5% higher than the approved budgetary allocations of $50.9 million. However, the expenditures on the FP objective of SPRHN of $2.2 million were 28% lower than the approved budgetary allocations of $3.1 million. At the same time, the FP objective budget execution in the 15 USAID assisted regions was much higher than the budget execution in non-USAID assisted regions, i.e., 99% and 31% respectively.

These investments contributed to the nationwide decrease of the abortion ratio by 46% and of teenage abortion rate by 43% between 2005 and 2011.

In all USAID assisted regions the higher investments in FP were associated with a reduction of abortion, while the birth rates increased. The incidence of child abandonment decreased by 58% in the USAID assisted regions; while in the non-USAID assisted regions it decreased by 42%.

Conclusions: The increase of the GOU investments in the national FP/RH program did not reduce fertility or birth rates, but significantly reduced the abortion rates. Additionally, when the evidence-based FP policies became part of the GOU agenda, they resulted in significant financial savings coming from the lower number of abandoned children.