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NCBI Bookshelf. This chapter discusses two related but conceptually distinct health concerns in low- and middle-income countries LMICs : a voluntary family planning, and b abortion, including postabortion care. In the first section, on family planning, the health condition of interest is unmet need: the percentage of women who would like to either stop or delay childbearing but who are not using any contraceptive method to prevent pregnancy. The unmet need for family planning to either limit family size or determine the intervals between children in unintended and unwanted pregnancies, which in turn lead to a broad range of maternal and child conditions that increase morbidity and mortality.

Surgical procedures for family planning can help reduce this unmet need, particularly the need to limit childbirth. The second section concerns surgery for induced abortion as opposed to spontaneous abortion, or miscarriage and the surgical management of the complications of induced, mostly unsafe, abortion. The demand for abortion is high in many LMICs, and the illegality of the procedure in most of these countries increases the likelihood of postabortion complications from clandestine, unsafe procedures Grimes and others ; Shah and Ahman ; Singh and others ; Singh Therefore, postabortion care is a ificant health issue in LMICs.

Timely, safe surgical interventions can reduce the morbidity and mortality associated with unsafe abortions. The same surgical procedures used for abortion are also used to manage incomplete abortion, which is one of the most common postabortion complications and is often accompanied by other complications such as bleeding, sepsis, and genital injury. The surgical procedures used to manage such complications include laparotomy for sepsis and uterine injury and a wide range of minor procedures to repair injuries to the proximal birth canal.

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Both sections discuss the burden of reproductive health conditions, including morbidity, mortality, and other effects. We discuss surgical procedures their performance, inputs, and implementation and the health workforce implications of scaling up those procedures in LMICs. Finally, we outline future directions—including implementation challenges and considerations for increasing access to these surgical interventions—and conclude by summarizing the findings and recommendations. Recent data illustrate how high the stakes can be, although some trends have improved during the past two decades.

The Global Burden of Disease GBD Study estimated that almostdeaths 4 perglobally were attributable to maternal conditions ina 29 percent decrease fromwhen there werematernal deaths 7 perLozano and others Almost 1. Family planning is one of the most effective, and cost-effective, interventions against maternal mortality and disability.

Increasing contraceptive coverage was primarily responsible for a substantial reduction in global fertility rates from 3. Despite a 42 percent increase in the of women of reproductive age 15—49 years old between andthe of births per year remained constant, and the mortality risk per birth decreased Ross and Blanc Meeting the need for family planning globally would further reduce maternal mortality by an estimated 29 percent, a reduction of more thandeaths annually Ahmed and others Moreover, family planning has both household and macroeconomic benefits.

At the household level, it reduces fertility—an important attribute given that women in LMICs increasingly desire better-planned and better-spaced families Darroch ; Darroch and Singh At the macroeconomic level, it reduces youth dependency and increases labor force participation by women, thereby enhancing economic growth Canning and Schultz Family planning comprises both traditional and modern methods of contraception.

Traditional methods, including withdrawal and fertility awareness, have low efficacy; up to 24 percent of women who use them will have unintended pregnancies within one year Trussell a. Modern methods—including sterilization, intrauterine devices IUDsinjections, implants, pills, and mechanical methods such as condoms—have higher effectiveness, resulting in lower rates of unintended pregnancies Trussell a.

Sterilization is the most common method of permanent family planning; most other methods are temporary. Permanent methods are indicated for couples who consider their families to be complete and would like to stop childbirth limit the of children. Temporary methods are indicated for couples who would like to delay childbirth to space children further apart or for other reasons. Contraception can also be divided into surgical methods, methods that employ minor surgery for insertion and removaland nonsurgical methods table 7.

Methods involving surgery or minor surgery are generally more effective than the nonsurgical methods. Surgery is employed primarily for sterilization.

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The most common male sterilization procedure is vasectomy, and the most common female sterilization procedure is tubal ligation. Vasectomy and tubal ligation are among the most effective of the modern contraceptive methods, having first-year failure rates of 0. Although some nonsurgical forms of female sterilization exist, they are either not available or not practicable for LMICs in the foreseeable future.

Contraceptive Prevalence. Globally, total contraceptive prevalence is 63 percent, defined as the percentage of women of reproductive age who report that they or their partners use at least one traditional or modern contraceptive method. Countries vary widely in this estimate by development status: contraceptive prevalence is 72 percent in developed countries and 54 percent in developing countries excluding China.

In Africa, it is even lower, at 31 percent; some countries, such as Chad, Mali, Sierra Leone, and Republic of South Sudan, have a contraceptive prevalence of less than 10 percent Alkema and others In LMICs, more than 25 percent of almost million sexually active women of reproductive age use low-efficacy traditional methods or no method at all.

Among women in LMICs who use modern contraceptive methods, a substantial proportion report that they or their partners use male or female sterilization: 10 percent in Sub-Saharan Africa, 64 percent in South and Central Asia, and 13 percent in Southeast Asia Darroch, Sedgh, and Ball ; Singh and Darroch Many factors, besides inadequate knowledge and poor-quality family planning services that are difficult to access, contribute to non-use of contraception:.

Other variables affecting contraceptive use or non-use include the of children already born Muyindike and othersage Muyindike and othersand race Frost, Singh, and Finer In LMICs overall, however, it is the most disadvantaged members of society who use contraceptives less often and have a higher unmet need for them. Unmet Need for Contraception. Globally, at least million women ages 15—49 years in a marriage or union have an unmet need for contraception, meaning that they want to either stop or delay childbearing but are using no contraceptive method to prevent pregnancy.

This corresponds to 11—14 percent of these partnered women, varying widely by income status. In high-income countries HICsthe unmet need is 9 percent and in developing countries, 13 percent 16 percent if China is excluded. In Africa, the unmet need is 23 percent, exceeding 35 percent in some countries, including Kenya, Rwanda, and Togo Alkema and others Among all women of childbearing age in developing countries who want to avoid pregnancy, more than million, or 26 percent, have an unmet need for modern contraceptive methods.

This unmet need varies widely by region: it is much higher in Africa 53 percent; 60 percent in Sub-Saharan Africa than in Latin America and the Caribbean 22 percent and Asia 21 percent Darroch and Singh Among all women of reproductive age who want to either stop or delay childbearing but use no contraception, the proportion of those who want to have no or no more children is a crude indicator of potential demand for permanent contraception, that is, sterilization. This proportion varies substantially by geography: it is 32 percent in Sub-Saharan Africa, 41 percent in North Africa, 50 percent in Central America, 57 percent in the Caribbean, 63 percent in Asia excluding Chinaand 64 percent in Southeast Asia Clifton and Kaneda Despite substantial variation, many women would like to avoid all or further childbirth and could benefit from expanded access to sterilization methods, which are predominantly surgical.

Trends in Prevalence and Unmet Need. During the period —, global contraceptive prevalence increased by 8 percentage points, from 55 percent to 63 percent. During the same period, unmet need for contraception decreased by 3 percentage points, from 15 percent to 12 percent Alkema and others However, prevalence has plateaued sinceespecially in the use of modern contraceptives Singh and Darroch : Among all women of reproductive age in LMICs, 57 percent used modern contraceptives in55 percent inand 55 percent in Among women in the poorest countries, use of modern contraception increased marginally, from 39 percent in to 40 percent in Meanwhile, the unmet need for modern contraceptive methods in developing countries decreased from 29 percent in to 26 percent in Darroch and Singh Although the unmet need decreased during this period in all LMICs, it remained far higher in Africa despite a reduction from 60 percent to 53 percentparticularly in Sub-Saharan Africa, where it decreased from 68 percent to 60 percent Darroch and Singh Moreover, modern contraceptive users in developing countries shifted away from surgical contraception sterilization to other forms.

The proportion using sterilization declined, on average, from 47 percent to 38 percent. In Africa overall, where sterilization use was already extremely low, it declined from 9 percent to 8 percent of modern contraceptive use, and in Sub-Saharan Africa, from 12 percent to 10 percent Darroch and Singh This decline is, however, relative: sterilization use is increasing in absolute terms, but use of other modern methods is increasing at an even faster rate. In addition to unwanted pregnancies, an unmet need for accessible, modern contraception has a variety of other consequences:.

Advantages of Sterilization. Sterilization is highly effective and offers permanent protection from unwanted pregnancy with none of the potential side effects of temporary contraceptive methods. Sterilization, whether of males or of females, eliminates the need for continuous involvement in family planning activities. It also spares couples and individuals some of the common worries associated with temporary methods, including partner compliance, domestic violence arising from disagreements between partners about fertility goalsinconvenience, side effects, supply needs, and the consequences of forgetfulness WHO Convenience and the longer duration of effective action are often the overriding factors in choosing contraceptives, and sterilization provides both of these advantages Steiner and others These positive factors may be even more attractive to couples in the lowest-income countries, where supplies may be irregular and health facilities may be substandard or far away from their homes.

However, surgical contraception and other nonbarrier methods also have an important limitation: they do not protect against human immunodeficiency virus HIV and other sexually transmitted infections. Barriers to Access. LMIC populations face a variety of demand- and supply-side barriers to access to surgical methods of family planning. Among the most important are individual attitudes and motivations: Some women want to have many children as a defense against high child mortality or as a source of future farm labor. Cultural and religious norms also impede access to surgical contraception.

Some cultures value high fertility, and some religions prohibit any form of contraception. In addition, lack of information le to misunderstanding, misconceptions, and myths about tubal ligation and vasectomy. Generally, information on surgical contraception is limited, particularly among unmarried individuals.

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Myths about surgical methods of contraception are also common. For instance, in Uganda, some men equate vasectomy to castration or loss of manhood, and some women associate tubal ligation with laziness, disinterest in sex, loss of menstrual regularity, and weight gain Kasedde Other barriers include fear of surgery, poverty and other economic barriers, geographic impediments such as living in remote rural areas, and poor health services and facilities Gaym ; Kasedde Studies also suggest that providers often have insufficient knowledge or motivation to provide surgical contraception Gaym

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