Ensuring human rights in the provision of contraceptive information and services Guidance and recommendations Annexes Annex A Guideline Steering Group Annex B Guideline Development Group Annex C Grade Summaries and Evidence Tables Annex D Health and human rights standards 1 WHO/RHR/14.02 Table of Contents Annex A Guideline Steering Group ............................................................................................................................................................ 2 Annex B Guideline Development Group .................................................................................................................................................... 3 Annex C Grade Summaries and Evidence Tables .................................................................................................................................... 6 Annex D Health and human rights standards.......................................................................................................................................... 36 2 Annex A Guideline Steering Group Lynn Bakimajian Carmen Barroso Leo Bryant Jane Cottingham Nel Druce Lynn Freedman Sofia Gruskin Karen Hardee Jane Hobson Sandra Jordan Eszter Kismodi Jan Kumar Karen Newman Mariela Rodriguez Kate Shaw WHO Staff Maria Rodriguez Monica Dragoman Rajat Khosla Lale Say Marleen Temmerman 3 Annex B Guideline Development Group The opinions reflected in this document are those of the individuals, and do not necessarily reflect the opinions or policies of the associated organizations or countries. Alfonso Barrangues UNFPA USA Harriet Birungi Population Council Kenya Shelah S. Bloom MEASURE Evaluation University of North Carolina at Chapel Hill United States of America (USA) Dirk Van Braeckel Ghent University Belgium Jacqueline Bryld Danish Family Planning Association Sex and Samfund Denmark Caroline Phiri Chibawe Mother and Child Health Ministry of Community Development Zambia Jacqueline Darroch Guttmacher Institute USA Suzanne Ehlers Population Action International USA Faustina Fynn-Nyame Marie Stopes International Ghana Ghana Christine Galavotti Sexual, Reproductive and Maternal Health CARE USA USA Baochang Gu Center for Population and Development Studies Renmin University of China China Demet Güral Technical and Program Strengthening Pathfinder International USA 4 Krishna Jafa Population Services International (PSI) India Sandra Jordan USAID USA Jane Kiragu Satima Consultants Ltd Kenya Sunita Kishor MEASURE DHS USA Rebecca Koladycz International Planned Parenthood Federation USA Tamara Kreinin Population and Reproductive Health Program The David and Lucile Packard Foundation USA Matthew Lindley International Planned Parenthood Federation United Kingdom Nyovani J. Madise Social Statistics & Demography University of Southampton United Kingdom Tarek Meguid University of Namibia, School of Medicine Namibia Poonam Mutreja Population Foundation of India India Nuriye Ortayli Reproductive Health UNFPA USA Jacqueline Pitanguy CEPIA Brazil Melanie Pleaner Wits Reproductive Health and HIV Research Institute University of the Witwatersrand South Africa Serge Rabier Equilibres & Populations France Scott Radloff Bill & Melinda Gates Institute for Population and Reproductive Health USA Sara Seims The David and Lucile Packard Foundation United Kingdom 5 Saroj Kumar Sikdar Ministry of Health India Sivananthi Thanenthiran The Asian–Pacific Resource & Research Centre for Women (ARROW) Malaysia Mountaga Toure The Malian Association for the Protection and Promotion of the Family Mali Esther Vicente University of Puerto Rico PROFAMILIA Puerto Rico Senorina Wendoh International Planned Parenthood Federation United Kingdom 6 Annex C Grade Summaries and Evidence Tables 1. NON-DISCRIMINATION Recommendation based on human rights standards (Annex D), no health evidence sought. 2. AVAILABILITY Recommendation 2.1 Integration of supply chain Date: 2013-04-11 Question: Should full intervention package vs partial intervention package be used for improve quality of family planning services? Settings: Uganda Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Full intervention package Partial intervention package Relative (95% CI) Absolute contraceptive experience of clients 11 observational studies serious2 no serious inconsistency no serious indirectness no serious imprecision3 none -4 - - - VERY LOW IMPORTANT 0% - 1 Okuello et al., 2003 2 High risk of bias as different subjects were assessed at baseline and follow-up. 3 While imprecision was not serious, some assessed groups (i.e. new clients) were small, with n<300. 4 Contraceptive experience score was 0.72 for the experimental group for new clients (full intervention) and 0.71 for the control group (partial intervention), indicating little difference between the full and partial interventions. 7 3. ACCESSIBILITY 3.1 Comprehensive sexuality education Author(s): P. Whyte Date: 2013-04-10 Question: Should theory-based multi-component educational program be used in high school students? Settings: USA - California and Texas Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Theory-based multi- component educational program Control Relative (95% CI) Absolute use of condoms at last intercourse (assessed with: survey) 11 randomised trials very serious2 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.68 (1.02 to 2.76)3 - LOW IMPORTANT 0% - 1 Coyle et al., 2001 2 High risk of bias due to self-report of outcome variables; no accounting for subjects lost to follow-up; and no statistical correction for multiple tests of significance. The paper argues that analyses were limited to primary and secondary hypotheses and that all other testing was considered exploratory. 3 Odds ratio based on 'multi-level' analysis using logistic or linear regression (type used for this outcome not specified). The use of condoms at last intercourse was a secondary outcome in the study, with frequency of intercourse without a condom and number of sexual partners without a condom the primary outcomes. 8 Author(s): P. Whyte Date: 2013-04-10 Question: Should curriculum based on social cognitive theory and social inoculation theory be used in school students grade 6 to 9? Settings: USA - California Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Curriculum based on social cognitive theory and social inoculation theory Control Relative (95% CI) Absolute condom use at last intercourse (assessed with: survey) 11 randomised trials very serious2 no serious inconsistency no serious indirectness no serious imprecision none - - - - LOW IMPORTANT 0% - 1 Coyle et al., 2004 2 High risk of bias due to use of self-report surveys for assessing outcomes; lack of participation from students who had permission to participate; high loss to follow-up of subjects. 9 Author(s): P. Whyte Date: 2013-04-10 Question: Should health belief model combined with social learning theory be used in adolescents aged 13-19 years?1 Settings: USA - California and Texas Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Health belief model combined with social learning theory Control Relative (95% CI) Absolute contraceptive efficiency (weighted composite index intended to assess consistency with which teenagers used effective methods before and after the intervention) (assessed with: interview) 12 observational studies serious3 no serious inconsistency no serious indirectness serious4 none -5 - - - VERY LOW IMPORTANT 0% - use of an effective contraceptive at most recent intercourse (assessed with: interview) 12 observational studies serious3 no serious inconsistency no serious indirectness serious4 none -6 - - - VERY LOW IMPORTANT 0% - 1 Program included four areas: factual information, group discussion of factual information, group discussion of values, feelings and emotions, and discussion of decision-making and personal responsibility for one's sexual behaviour. 2 Eisen 1990 3 Only 60% of the baseline sample completed one year follow-up interviews. 4 Some analyses were based on small subgroups of the total sample (n=81) and main analyses included only 60% of those who completed follow-up. 5 For males there was no statistically significant difference in contraceptive efficiency at one year follow-up. For females there was a statistically significant advantage favouring the control group, with a contraceptive efficiency score of 6.95 for the intervention group and 12.00 for the control group (p<0.01); higher score is better. 6 For males, the use of effective contraception was greater in the control group, 65% compared to 55% in the intervention group. For females, 35% in the intervention group and 65% in the control group reported using effective contraception for their most recent intercourse. 10 Author(s): P. Whyte Date: 2013-04-10 Question: Should peer-led sex education vs teacher-led sex education be used in high school students? Settings: UK Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Peer-led sex education Teacher-led sex education Relative (95% CI) Absolute used contraception at first sex - females (assessed with: questionnaire) 11 randomised trials serious2 no serious inconsistency no serious indirectness no serious imprecision none - - OR 0.90 (0.73 to 1.11)3 - MODERATE IMPORTANT 0% - used contraception at first sex - males (assessed with: questionnaire) 11 randomised trials serious2 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.01 (0.68 to 1.49)3 - MODERATE IMPORTANT 0% - 1 Stephenson et al., 2004 2 Some risk of bias given that outcomes were self-reported. The paper states that substantial bias seems improbable however no rationale for this claim is provided. 3 The paper reports n and percentage using contraception at first sex, but does not report the total N. The referenced webpages with additional tables (which may have total N) no longer exist. Therefore proportions cannot be entered in GRADE. 11 Author(s): P. Whyte Date: 2013-04-10 Question: Should peer-led sex education vs teacher-led sex education be used in high school students? Settings: UK Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Peer-led sex education Teacher-led sex education Relative (95% CI) Absolute used any contraception at first sex - females (assessed with: questionnaire) 11 randomised trials serious2 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.07 (0.88 to 1.31)3 - MODERATE IMPORTANT 0% - used any contraception at first sex - males (assessed with: questionnaire) 11 randomised trials serious2 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.04 (0.65 to 1.68)3 - MODERATE IMPORTANT 0% - used any contraception at last sex - females (assessed with: questionnaire) 11 randomised trials serious2 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.57 (1.08 to 2.29)3 - MODERATE IMPORTANT 0% - used any contraception at last sex - males (assessed with: questionnaire) 11 randomised trials serious2 no serious inconsistency no serious indirectness no serious imprecision none - - OR 0.66 (031 to 1.39)3 - MODERATE IMPORTANT 0% - 1 Stephenson et al., 2008 2 Some risk of bias given that outcomes were self-reported. 3 The paper reports n and percentage using contraception at first sex for intervention and control groups, but does not report the total N for each group. Therefore proportions cannot be entered in GRADEVERY. 12 Recommendation 3.2 Removal of financial barriers Author(s): P. Whyte Date: 2013-04-10 Question: Should contraceptive method of choice at no cost be used in women in St. Louis region?1 Settings: USA Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Contraceptive method of choice at no cost Control Relative (95% CI) Absolute use of long-acting contraceptive method 12 observational studies serious3 no serious inconsistency no serious indirectness no serious imprecision none -4 - - - VERY LOW IMPORTANT 0% - 1 There is no comparison with use of contraceptives at cost. 2 Secura et al., 2010 3 Observational study reporting only proportion who chose contraception. 4 Study reports only that 67% of women who enrolled chose long-acting contraceptive methods. 2500 enrolled. No details on number assessed. 13 Author(s): P. Whyte Date: 2013-04-10 Question: Should no intervention be used in male college students?1 Settings: China Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations No intervention Control Relative (95% CI) Absolute condom use during most recent sexual encounter (assessed with: survey) 12 observational studies serious3 no serious inconsistency no serious indirectness no serious imprecision none -4 - - - VERY LOW IMPORTANT 0% - provision of free condoms (assessed with: survey) 12 observational studies serious3 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.98 (1.08 to 3.61)5 - VERY LOW IMPORTANT 0% - 1 This study did not use an intervention. It assessed current condom use in male college students. 2 Long et al., 2012 3 Paper reports that study represents only a small sample of college students and results may not be representative. In addition, results are based on retrospective data, when condom use may be best measured using daily calendars. 4 The paper reports only that 61.5% of subjects used a condom during their most recent sexual encounter, no Ns are provided. 5 Odds ratio for condom use when free condoms were available. When free reproductive health counselling was available, odds ratio for use of condoms was 1.54 (95% CI: 1.08, 2.74) compared to no counselling. 14 Author(s): P. Whyte Date: 2013-04-10 Question: Should contraceptive method of choice at no cost be used in women in St. Louis region?1 Settings: USA Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Contraceptive method of choice at no cost Control Relative (95% CI) Absolute use of long-acting contraceptive method 12 observational studies serious3 no serious inconsistency no serious indirectness no serious imprecision none -4 - - - VERY LOW IMPORTANT 0% - 1 There is no comparison with use of contraceptives at cost. 2 Peipert et al., 2012 3 Observational study reporting only proportion who use long-acting method of contraception. 4 Paper reports that 75% of participants chose a long-acting method of contraception. This is a follow-up to the Secura et al (2010) paper which reported 67% in first 2500 participants. Primary outcomes were abortions, repeat abortions and teenage births. 15 Recommendation 3.3 Improving access for populations with difficulties accessing services (Evidence on rural population) Author(s): P. Whyte Date: 2013-03-20 Question: Should lady health worker program vs no program be used in married women?1 Settings: Pakistan Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Lady health worker program No program Relative (95% CI) Absolute use of modern reversible contraceptive method (assessed with: survey) 12 observational studies3 serious4 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.50 (1.04 to 2.16)5 - VERY LOW IMPORTANT 0% - 1 Lady health workers deliver services related to child and maternal health. 2 Douthwaite and Ward 2002 3 Retrospective review of data. 4 High risk of bias given observational nature of the study. In addition, no baseline data was collected. 5 Based on multivariate logistic regression analysis. The paper provided only percentages (not Ns) for the intervention and control group for proportion using modern reversible methods of contraception. 16 Author(s): P. Whyte Date: 2013-03-20 Question: Should traditional medical practitioners to deliver family planning services be used in rural population? Settings: Uttar Pradesh, Muzaffamagar District Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Traditional medical practitioners to deliver family planning services Control Relative (95% CI) Absolute use of contraceptive methods (assessed with: survey) 11 observational studies serious2 no serious inconsistency no serious indirectness no serious imprecision none 508/800 (63.5%)3 413/850 (48.6%) - 486 fewer per 1000 (from 486 fewer to 486 fewer) VERY LOW IMPORTANT 0% - 1 Kambo 2 Observational study, areas included were 'purposively' selected. 3 Greater increase in contraceptive use from baseline to follow-up in intervention group as opposed to control group. Values presented here are for follow-up. Author(s): P. Whyte Date: 2013-03-20 Question: Should delivery of improved services for health be used in rural population? Settings: Uganda Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Delivery of improved services for health Control Relative (95% CI) Absolute current contraceptive use (assessed with: survey) 11 observational studies2 serious3 no serious inconsistency no serious indirectness no serious imprecision none - - -4 - VERY LOW IMPORTANT 0% - 1 Katende et al., 2003 2 Retrospective review of data. 3 High risk of bias as analysis is limited to facility-based information only and did not take into account other programmatic interventions that may have had an impact. 4 Paper reports that none of the measures of service delivery was significantly associated with modern method use of contraceptives among women living in rural areas. 17 Author(s): P. Whyte Date: 2013-03-20 Question: Should community-based approach be used in a rural population? Settings: Pakistan Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Community-based approach Control Relative (95% CI) Absolute use of modern reversible method of contraception (assessed with: survey) 11 observational studies2 serious3 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.74 (1.11 to 2.71)4 - VERY LOW MPORTANT 0% - 1 Sultan et al., 2002 2 Retrospective review of survey data. 3 Retrospective review of data therefore limiting ability to link causal factors. 4 Adjusted odds ratio indicating that women living within 5km of two community-based workers were significantly more likely to be using a modern contraceptive method compared to those with no access to community workers 18 Recommendation 3.4 Displaced populations Author(s): P. Whyte Date: 2013-03-28 Question: Should community-based providers in emergency setting be used in refugee population? Settings: eastern Burma Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Community-based providers in emergency setting Control Relative (95% CI) Absolute use of modern methods of contraception (assessed with: survey) 11 observational studies no serious risk of bias no serious inconsistency no serious indirectness no serious imprecision none 1070/2377 (45%)2 - prevalence rate ratio 1.88 (1.63 to 2.17)3 - LOW IMPORTANT 0% - 1 Mullany et al., 2010 2 This is the proportion using modern contraception at endpoint. The proportion using modern contraception at baseline was 23.9%. 3 Comparing baseline and endpoint. 19 Recommendation 3.5 Integration with HIV Author(s): P. Whyte Date: 2013-03-05 Question: Should integration of HIV/AIDS services with maternal, neonatal and child health, nutrition and family planning services be used for maternal and child mortality and control HIV/AIDS epidemic?1 Settings: All countries2 Bibliography: Lindegren et al., 2012 Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition and family planning services Control Relative(95% CI) Absolute uptake of contraception (Ethiopia) 13,4 observational studies very serious5 no serious inconsistency no serious indirectness no serious imprecision none 212/3374 (6.3%)6 - - - VERY LOW IMPORTANT 0% - uptake of contraception (Ethiopia) 13,7 observational studies very serious5 no serious inconsistency no serious indirectness no serious imprecision none 474/677 (70%)6,8 - - - VERY LOW IMPORTANT 0% - uptake of contraception (Malawi; HIV positive women) 13,9 observational studies very serious5 no serious inconsistency no serious indirectness serious10 none 92/200 (46%)6,11 - - - VERY LOW IMPORTANT 0% - couple unit of protection (CYP) calculated by dividing the total quantity uptake of each FP commodity by duration of protection provided, assuming an average of 10 acts per month (Nigeria) 13,12 observational studies very serious5 no serious inconsistency no serious indirectness no serious imprecision none -13 - - - VERY LOW IMPORTANT 0% - uptake of contraception (Kenya) 13,14 observational studies very serious15 no serious inconsistency no serious indirectness no serious imprecision none -6 - OR 4.0 (3.0 to 5.3)16 - VERY LOW IMPORTANT 0% - uptake of contraception (Tanzania) 13,17 observational studies very serious5 no serious inconsistency no serious indirectness no serious imprecision none 172/407 (42.3%) - OR 1.23 (0.87 to 1.72)18 - VERY LOW IMPORTANT 0% - 20 1 This is the health problem identified in the systematic review. The review question this was contained under for the Guidance was "Are there interventions which, compared to baseline care (no intervention), are effective at improving equitable access to FP information and services for users or potential users". The specific research question was "Is there evidence that integration with HIV services improves accessibility of FP services?". 2 The Lindegren et al (2012) review included high, middle and low income countries as defined by the World Bank. The studies which reported on contraceptive use were conducted in low and middle income countries. 3 The Lindegren et al (2012) review stated that seven studies (of the 19 in the review) reported on contraceptive use. Given that the review did not include any data from the studies and instead just stated that "All seven studies that reported on contraceptive use showed positive results, with an increase in family planning use (both condom and non-condom methods) reported" this GRADE table will report each of the available studies separately. Two of the cited studies (Brou et al., 2009 and King et al., 1995) were not available and as there were no results provided in the Lindegren review, results are not presented. 4 Bradley et al., 2009 5 High risk of selection bias, lack of blinding therefore high risk of performance bias, all outcomes were self-reported, therefore high risk of reporting bias. 6 This is men and women combined who reported use of contraception post-intervention. The paper indicates this was a significant increase from pre-intervention, where usage was 0.1% for women and 0.8% for men.. 7 Gillespie et al., 2009 8 This was the proportion of women in current sexual unions who were using contraception. 9 Hoffman et al., 2008 10 Small sample size with n=227. 11 The 46% is women using contraception at 1month follow-up. At 1-week follow-up 52% were using contraception. The N of 200 accounts for those lost to follow-up and those who died during the study. 12 Chabikuli et al., 2009 13 Paper reports mean monthly CYP of 38.2 following the intervention, compared to 32.3 prior to the intervention, a significant increase. these results are based on 44,589 people who attended FP clinics during the review period. 14 Ngure et al., 2009 15 High risk of selection bias, lack of blinding with unclear risk of performance bias, and high risk of other bias as HIV positive women had greater visit frequency and greater contraception uptake than HIV negative women. 16 This OR is based on comparison of proportion of visits where non-condom contraceptive use was reported, for HIV-positive women. For HIV-negative women the OR=2.2 (95% CI: 1.4, 3.5). 17 Rasch et al., 2006 18 Adjusted OR (influence of age, marital situation, previous birth and occupation) based on comparison with those who refused HIV test (97/299; 32.9%). 21 Recommendation 3.6 Integration postpartum Author(s): P. Whyte Date: 2013-03-13 Question: Should education for contraceptive use by women postpartum be used in women following childbirth?1,2 Settings: US and four other countries3 Bibliography: Lopez et al., 2012 Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Education for contraceptive use by women postpartum Control Relative(95% CI) Absolute contraceptive use postpartum (assessed with: interview) 14 randomised trials serious5 no serious inconsistency no serious indirectness serious6 none 170/299 (56.9%)7 19/301 (6.3%)8 - 63 fewer per 1000 (from 63 fewer to 63 fewer) LOW IMPORTANT 0% - contraceptive use postpartum 19 randomised trials no serious risk of bias no serious inconsistency no serious indirectness no serious imprecision none 117/276 (42.4%)10 118/291 (40.5%) - 405 fewer per 1000 (from 405 fewer to 405 fewer) HIGH IMPORTANT 0% - contraceptive use postpartum (assessed with: interview) 111 randomised trials serious12 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.62 (1.06 to 2.50)13 - MODERATE IMPORTANT 0% - contraceptive use postpartum (assessed with: interview) 114 randomised trials serious15 no serious inconsistency no serious indirectness serious16 none 53/62 (85.5%) 40/62 (64.5%) RR 1.33 (1.07 to 1.64) 213 more per 1000 (from 45 more to 413 more) LOW IMPORTANT 0% - contraceptive use postpartum (assessed with: questionnaire and collection of pill packs) 117 randomised trials serious18 no serious inconsistency no serious indirectness serious19 none 4/16 (25%)20 3/9 (33.3%)21 - 333 fewer per 1000 (from 333 fewer to 333 fewer) LOW IMPORTANT 0% - 22 1 The Lopez et al (2012) review states that of the ten included studies only five had contraceptive use as an outcome. The review did not provide any pooled analyses of the available studies. Consequently, each study is presented individually here. 2 Five of the studies in the Lopez et al (2012) review focused on adolescents and one on young women, the remainder did not have age limits. Of the studies focusing on adolescents, only two had contraceptive use as an outcome. 3 There were ten studies included in the Lopez et al (2012) review, six conducted in the USA, one in each of Australia, Nepal, Pakistan and Syria. 4 Saeed et al., 2008. Intervention was contraceptive counselling following birth plus an educational leaflet. 5 No information was provided regarding allocation concealment. 6 Intervention consisted of one 20 minute informal counselling session and a one page pamphlet on contraceptive methods. The Lopez et al (2012) review downgraded the study due to low intervention quality. 7 An additional 129 (43.1%) indicated they would start using contraception in the next 6 months. 8 An additional 153 (50.8%) indicated they would start using contraception in the next 6 months. 9 Bashour et al., 2008. Intervention was either 4 post-natal home visits or one post-natal home visit. 10 There were two intervention groups in this trial. The first, with 4 intervention visits had 42.2% of subjects using contraception. The second group, with one intervention visit, had 37% (107/289) using contraception. 11 Bolam et al., 1998. intervention included structured baseline household questionnaire, one-to-one health education at birth and 3 months later. 12 Subjects and health educators were not blinded. There was also a high loss to follow-up, with 25% lost to follow-up at 3 months and 27% at 6 months. 13 There were three experimental and one control group in this study. The three experimental groups received either health education immediately after birth and 3 months postpartum (group A), health education at birth only (group B), health education at 3 months (group C). The control group (group D) received no health education. The paper compared groups A and B combined to groups C and D combined and that is the odds ratio presented here. No proportions of patients in each group using contraception can be presented in GRADE because the paper did not provide the number assessed in each group, only the overall N assessed. The paper also compared groups A and C versus groups B and D. This produced an OR of 0.86 (95% CI: 0.58, 1.35) for the comparison of contraceptive use at 6 months. There were no comparisons of the experimental groups versus the control group alone. 14 Quinlivan et al., 2003. Intervention was five structured post-natal home visits by nurse midwives. 15 Unclear risk for performance bias and detection bias given no information was provided in regard to blinding. 16 Small N with 139 enrolled and 124 assessed. 17 Gilliam et al., 2004. Intervention consisted of counselling, a videotape about oral contraceptives and written material. 18 Unclear risk of performance bias and detection bias due to lack of information regarding blinding. 19 Small n with only 33 randomised and 52% had dropped out at one year follow-up. 20 These are proportions of women still using oral contraceptives at one year. Another 8 had switched to other methods of contraception. The paper provides the Ns but the percentages reported in the paper are based on the total number of subjects (n=25) instead of by group, as calculated by GRADE. 21 These are proportions of women still using oral contraceptives at one year. Another 3 had switched to other methods of contraception. The paper provides the Ns but the percentages reported in the paper are based on the total number of subjects (n=25) instead of by group, as calculated by GRADE. 23 Recommendation 3.7 Integration with post abortion and abortion services Author(s): P. Whyte Date: 2013-03-05 Question: Should post-abortion family planning counselling be used for women in low-income countries?1 Settings: low-income countries Bibliography: Tripney et al., 2013 (The Tripney review does not offer any pooled results nor does it provide adequate detail to enter any relevant results into GRADE. Therefore the individual studies were used) Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Post-abortion family planning counselling Control Relative(95% CI) Absolute repeat abortions 12 observational studies serious3 no serious inconsistency no serious indirectness serious4 none 7/276 (2.5%) 15/281 (5.3%) - 53 fewer per 1000 (from 53 fewer to 53 fewer)5 VERY LOW IMPORTANT 0% - repeat unplanned pregnancy - modern contraception 12 observational studies serious3 no serious inconsistency no serious indirectness serious4 none 42/276 (15.2%) 96/281 (34.2%) OR 3.38 (2.16 to 5.29) 295 more per 1000 (from 187 more to 391 more) VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods (assessed with: interview) 16 observational studies very serious7 no serious inconsistency no serious indirectness no serious imprecision none 378/456 (82.9%)8 - - - VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods at 6 months post intervention (assessed with: interview) 19 randomised trials no serious risk of bias no serious inconsistency no serious indirectness serious10 none 121/123 (98.4%) 86/123 (69.9%) RR 1.41 (1.25 to 1.58) 287 more per 1000 (from 175 more to 406 more) MODERATE IMPORTANT 0% - acceptance and/or use of contraceptive methods (assessed with: interview) 111,12 observational studies very serious13 no serious inconsistency no serious indirectness no serious imprecision none - - - - VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods (assessed with: interview) 114 observational studies very serious15 no serious inconsistency no serious indirectness no serious imprecision none 979/1009 (97%)16 - - - IMPORTANT 24 Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Post-abortion family planning counselling Control Relative(95% CI) Absolute repeat abortions 0% - VERY LOW acceptance and/or use of contraceptive methods (assessed with: review of procedure logbooks) 117 observational studies no serious risk of bias no serious inconsistency no serious indirectness no serious imprecision none 3492/4462 (78.3%)18 - - - LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods (assessed with: interview) 119 observational studies serious20 no serious inconsistency no serious indirectness no serious imprecision none 271/315 (86%)21 - - - VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods (assessed with: interview with physicians, 'perusal' of client records, interview with patients) 122 observational studies very serious23 no serious inconsistency no serious indirectness no serious imprecision none - - - - VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods 124 observational studies very serious25 no serious inconsistency no serious indirectness no serious imprecision26 none - - - - VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods (assessed with: interview) 127,28 observational studies none - - - - VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods 129 observational studies very serious30 no serious inconsistency no serious indirectness no serious imprecision none 487/524 (92.9%)31 - - - VERY LOW IMPORTANT 0% - acceptance and/or use of contraceptive methods (assessed with: interview) 132 observational studies very serious33 no serious inconsistency no serious indirectness no serious imprecision none 495/521 (95%)34 - - - VERY LOW IMPORTANT 0% - 1 There are 3 identified papers that do not provide any relevant information and cannot be entered into GRADE given the characteristics of the papers. McLaurin et al., 1995 is a paper which describes issues around post-abortion care and lists a number of recommendations made by a working group regarding private and public abortion services. There are no interventions described in this paper, nor any subjects, nor any results. The Maila et al (1997) paper describes post abortion care instituted in Nepal in 1995 and states that acceptance of family planning has been high, at 70%. There is no indication of the number of patients involved. The paper also stated that family planning "generally has involved counselling of both husband and wife", but it also states that counselling was provided to all patients. The Postabortion family planning November 2012 paper describes aspects of a number of programs and summarises the proportion of women receiving contraception before and after family planning services were 'strengthened' across countries. Entering these results into GRADE is not possible. 2 Johnson et al., 2002 25 3 Study only included women who wanted to postpone their next pregnancy for at least two years. This would suggest potential for increased interest or use of family planning. 4 For most outcomes the number of events was less than 300 (GRADE threshold rule of thumb value). 5 Calculated by GRADE - no relative or absolute effects provided in the paper. 6 Ministry of Health Burkina Faso 1988 7 There is no indication the patients interviewed before and after the intervention are the same - the paper reports 300 patients were interviewed prior to the intervention and 456 after the intervention. 8 There was no control group in this study, hence no results. The paper did not provide any relative or absolute effects for the pre- and post-intervention differences - only the proportion using a family planning method was reported. 9 Ferreira et al., 2011 10 Total N less than 300. 11 Diaz et al. 12 No results from this study can be entered into GRADE. The paper provides only the average number of women seen for post-abortion complications at 3 hospitals and then provides the percentage accepting contraception at 3 different time points by type of contraception (percentages range from 4.3% to 39.0%). GRADE requires that numerators and dominators are entered, the percentage alone cannot be entered. The Ns in this study cannot be determined from the information provided in the paper. 13 Observational study involving program instituted at 3 hospitals. There appears to be some inconsistency between the actual programs at each hospital and the authors mention repeatedly differing levels of 'acceptance' in the different areas. 14 Mahomed et al., 1997 15 There is potential for bias given that the N does not seem to be consistent - there are more patients presented post-intervention than prior to intervention. In addition, there is no control group. 16 There is no control group, and no relative or absolute effects in regard to before-after intervention differences were provided. 17 Otsea et al., 2011 18 There is no comparator group and no relative or absolute difference relative to pre and post-program differences. 19 Rasch et al., 2004 20 The study does not account for patients lost to follow-up; follow-up time varied from one to six months. 21 There is no control group; study does not provide any assessment of relative or absolute effects, just the percentages. 22 Rogo et al., 1998 23 No indication of how many physicians actually participated. Only result provided in terms of contraceptive acceptance or use was that between 12.5% and 100% of clients left the facility with a family planning method. No details on type of method or whether it was actually used was provided. 24 Solo et al., 1999 25 Study used three different family planning models, ie who delivered and where the family planning services were delivered varied. The only results relative to use of contraceptives was the proportion of patients who left the hospital with a contraceptive method, which was identified as 82% for model 1 (FP services provided on gynecological ward by staff), 63% for model 2 (FP services provided on gynecological ward by maternal and child health staff) and 75% for model 3 (FP services provided in maternal and family planning clinic by staff). Ns of patients in each model, either exposed to it or providing results, are not provided. Commencement of programs varied across models and sites as well. 26 Number of patients using the different models is unknown. 27 Thapa et al., 2004 28 This study assessed manual vacuum aspiration (MVA) services in Nepal, comparing them to abortion services offered in the main operation theatre. As such, it does not directly address post- abortion family planning counselling, although patients received some counselling. It does provide the proportion of MVA patients using contraceptives at 6 weeks following abortion, which was 53.5%. The paper indicates this was on the basis of 85 subjects. The paper states that 529 cases were treated in the MVA unit, and the n=85 represents only 16% of patients. The paper states that 83.6% of the MVA group appeared for the 6 week follow-up, so the disparity in Ns is not clear. 29 Rasch et al., 2005 30 It appears that slightly different counselling programs were offered across hospitals. There is no comparison with use of contraception prior to counselling for the women included, therefore it is difficult to assess impact of the program. 31 This percentage was for women in urban Tanzania. The results for rural Tanzania were 172 of 242 women being provided with a contraceptive method (71%). 32 Rasch et al., 2007 33 There is high risk of bias given the observational nature of the study and the lack of any comparison to use of contraception prior to counselling. 34 95% left the hospital ward with a contraceptive method. The female condom was accepted by 201 of 521 women (39%) and used by 158 of 521 (30%). 26 Recommendation 3.8 Mobile services Author(s): P. Whyte Date: 2013-04-10 Question: Should mobile outreach service delivery be used in women? Settings: Pakistan Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Mobile outreach service delivery Control Relative (95% CI) Absolute discontinuation of intrauterine device 11 observational studies serious2 no serious inconsistency no serious indirectness no serious imprecision none -3 - - - VERY LOW IMPORTANT 0% - 1 Azmat et al., 2013 2 Interviews were retrospective in nature and therefore recall bias may occur; also data was self-reported. 3 19.4% discontinued IUD use at 10 months (95% CI: 16.3, 22.5). Author(s): P. Whyte Date: 2013-04-10 Question: Should mobile outreach service be used in women fitted with IUDs and implants? Settings: Ethiopia, Myanmar, Pakistan, Sierra Leone, Vietnam Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Mobile outreach service Control Relative (95% CI) Absolute discontinuation of IUD 11 observational studies no serious risk of bias no serious inconsistency no serious indirectness no serious imprecision none -2 - - - LOW IMPORTANT 0% - 1 Eva and Ngo 2010 2 Percentage discontinuing at 8 months was: for implant: 5.7% in Ethiopia and 6.2% in Sierra Leone; for IUD: 16.9% in Sierra Leone, 20.9% in Myanmar, 18.9% in Pakistan and 2.3% in Viet Nam. 27 Author(s): P. Whyte Date: 2013-04-10 Question: Should mobile outreach service for IUD be used in women? Settings: Philippines Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Mobile outreach service for IUD Control Relative (95% CI) Absolute discontinuation of IUD 11 observational studies2 no serious risk of bias no serious inconsistency no serious indirectness no serious imprecision none 151/1348 (11.2%) - - - LOW IMPORTANT 0% - 1 Ngo and Pernito 2010 2 Retrospective review of data. One year discontinuation rates of IUD among mobile clinic users Author(s): P. Whyte Date: 2013-03-20 Question: Should community-based approach be used in a rural population? Settings: Pakistan Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Community-based approach Control Relative (95% CI) Absolute use of modern reversible method of contraception (assessed with: survey) 11 observational studies2 serious3 no serious inconsistency no serious indirectness no serious imprecision none - - OR 1.74 (1.11 to 2.71)4 - VERY LOW 0% - 1 Sultan et al., 2002 2 Retrospective review of survey data. 3 Retrospective review of data therefore limiting ability to link causal factors. 4 Adjusted odds ratio indicating that women living within 5km of two community-based workers were significantly more likely to be using a modern contraceptive method compared to those with no access to community workers 28 Recommendation 3.9 Elimination of third party authorization Based on human rights standards (Annex E), no health evidence search Recommendation 3.10 Elimination of parental notification Based on human rights standards (Annex E), no health evidence search 4. ACCEPTABILITY Recommendation 4.1 Counselling interventions Author(s): P. Whyte Date: 2013-04-11 Question: Should self-assessment and/or peer review of providers vs no self-assessment or peer review be used in service providers? Settings: Indonesia Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Self assessment and/or peer review of providers No self assessment or peer review Relative (95% CI) Absolute clients' rating of satisfaction 11 observational studies serious2 no serious inconsistency no serious indirectness no serious imprecision none -3 - - - VERY LOW IMPORTANT 0% - 1 Kim et al., 2000 2 Authors note that quality improvements cannot be related to outcome behaviours such as continued contraceptive use. 3 Paper reports that in the self-assessment intervention group there were significant increases in client satisfaction with provider attentiveness (4.3 to 4.4) and with needs met (4.1 to 4.3) on a non validated scale. The paper does not provide any statistical results supporting the claim of 'significant increases'. 29 Author(s): P. Whyte Date: 2013-04-11 Question: Should balanced counselling strategy be used in physicians and social workers? Settings: Guatemala Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Balanced counselling strategy Control Relative (95% CI) Absolute family planning use rates 11 observational studies no serious risk of bias no serious inconsistency no serious indirectness no serious imprecision none -2 - - - LOW IMPORTANT 0% - 1 Leon et al., 2003 2 The paper provided only graphs with use rates and values could not be ascertained. The paper stated that family planning use rates were inconsistent with the hypothesis of the study - that continuation in family planning would increase following improvements in quality of care. Instead, use of family planning appeared to decrease. Author(s): P. Whyte Date: 2013-04-11 Question: Should improvement of client-provider interactions vs no intervention be used in women? Settings: Egypt Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Improvement of client- provider interactions No intervention Relative (95% CI) Absolute satisfaction with clinic services 11 observational studies serious2 no serious inconsistency no serious indirectness no serious imprecision none -3 - - - VERY LOW IMPORTANT 0% - 1 Nawar et al., 2004 2 Risk of attrition bias as slightly less than half of women returned to clinics at follow-up visits. 3 Paper reports that at 7 month follow-up 72% in the intervention group were satisfied with clinic services compared to 55% in control group. At 13 month follow-up, 81% in intervention group and 61% in control group were satisfied. 30 Author(s): P. Whyte Date: 2013-04-11 Question: Should communication skills training program vs no training program be used in healthcare providers?1 Settings: Iran Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Communication skills training program No training program Relative (95% CI) Absolute client satisfaction 12 randomised trials serious3 no serious inconsistency no serious indirectness serious4 none 30/47 (63.8%) 16/47 (34%) - 340 fewer per 1000 (from 340 fewer to 340 fewer) LOW IMPORTANT 0% - 1 Additional communication skills training program in addition to regular education. 2 Yazdi et al., 2008 3 Authors state that outcome assessment in regard to client satisfaction is limited given a wide range of questionnaires was not used. 4 Number of clients (n=47) in both intervention and control groups) is small. Recommendation 4.2 Follow-up Based on human rights standards (Annex D), no health evidence search 31 5. QUALITY Recommendation 5.1 Quality assurance processes Author(s): P. Whyte Date: 2013-04-11 Question: Should national adolescent friendly clinic initiative vs control clinics be used in adolescents?1 Settings: South Africa Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations National adolescent friendly clinic initiative Control clinics Relative (95% CI) Absolute overall clinic score (assessed with: interview) 12 observational studies serious3 no serious inconsistency no serious indirectness no serious imprecision none -4 0% - - VERY LOW IMPORTANT 1 The national adolescent friendly clinic initiative (NAFCI) was based on a quality triangle including defining quality, improving quality and measuring quality. Quality was defined as standards of adolescent friendly services and the standards and criteria were developed on the basis of established characteristics and attributes of adolescent-friendly services. Measuring quality was done using a self-audit process and external assessment. Improving quality included forming teams in each clinic, with externally trained facilitators to support the team. 2 Dickson et al., 2007 3 Paper notes risk of selection bias, lack of statistical power due to small number of clinics (11 experimental, 11 control) and lack of adolescent clients at some clinics (simulations were performed instead of actual client-provider interactions). 4 The paper reports that the average clinic score of all experimental clinics was 79.9% compared to the control group clinics at 60.9% (p=0.005). 32 Author(s): P. Whyte Date: 2013-04-11 Question: Should improvement of client-provider interactions vs no intervention be used in women? Settings: Egypt Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Improvement of client- provider interactions No intervention Relative (95% CI) Absolute satisfaction with clinic services 11 observational studies serious2 no serious inconsistency no serious indirectness no serious imprecision none -3 - - - VERY LOW IMPORTANT 0% - 1 Nawar et al., 2004 2 Risk of attrition bias as slightly less than half of women returned to clinics at follow-up visits. 3 Paper reports that at 7 month follow-up 72% in the intervention group were satisfied with clinic services compared to 55% in control group. At 13 month follow-up, 8!% in intervention group and 61% in control group were satisfied. Recommendation 5.2 Management of Long acting contraceptives Based on human rights standards (Annex E), no health evidence search Recommendation 5.3 Provider training Based on human rights standards (Annex E), no health evidence search 6. INFORMED DECISION MAKING Recommendations 6.1 and 6.2 are based on human rights standards (Annex D). No health evidence search conducted. 7. PRIVACY AND CONFIDENTIALITY Recommendations 7.1 is based on human rights standards (Annex D). No health evidence search conducted. 33 8. PARTICIPATION Recommendation 8.1 Author(s): P. Whyte Date: 2013-03-10 Question: Should local initiatives program be used in residents of northern India?1 Settings: India Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Local initiatives program Control Relative (95% CI) Absolute increase in contraceptive use2 (assessed with: survey) 13 observational studies very serious4 no serious inconsistency no serious indirectness no serious imprecision none - - - - VERY LOW IMPORTANT 0% - 1 The study assessed local initiatives programs in three areas in India - the slums of Kolkata, Punjab and Hinmachal Pradesh and Uttaranchal. 2 The proportions using contraception at baseline and at the end of the programs were presented. The paper states that all three locations in the study ended the project with contraceptive use near or above 60%. The paper provides no numbers indicating how many individuals made up the result proportions. The paper also states that this usage of contraception represents a 78% increase in contraceptive use on average. It is not clear how this increase was calculated. 3 Paxman et al., 2005 4 The baseline measures in this study were taken 3 months after the programs had commenced. The methods used across the three locations of the study varied, limiting the ability to combine results. 34 Author(s): P. Whyte Date: 2013-03-10 Question: Should empowerment of female community health volunteers be used in married women of reproductive age? Settings: Nepal Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Empowerment of female community health volunteers Control Relative (95% CI) Absolute use of contraceptives 11 observational studies no serious risk of bias no serious inconsistency no serious indirectness serious2 none 130/241 (53.9%)3 - - - VERY LOW IMPORTANT 0% - satisfaction with consultation 11 observational studies no serious risk of bias no serious inconsistency no serious indirectness serious2 none 188/241 (78%) - - - VERY LOW IMPORTANT 0% - 1 Shrestha 2002 2 Sample size assessed was small with n=241. 3 This represented a significant increase over baseline, when none of the subjects used contraception. 35 9. ACCOUNTABILITY Recommendation 9.1 and 9.2 are based on human rights standards (Annex D). An evidence search on performance based financing resulted in one low quality study. The need for research on the effectiveness of performance based financing’s impact on contraceptive availability and human rights was noted. Author(s): P. Whyte Date: 2013-04-11 Question: Should financing to a for-profit company to provide family planning services be used? Settings: Kenya Bibliography: Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Financing to a for-profit company to provide family planning services Control Relative (95% CI) Absolute number of family planning clients 11 observational studies2 no serious risk of bias no serious inconsistency no serious indirectness no serious imprecision none -3 - - - LOW IMPORTANT 0% - 1 Chee et al., 2003 2 Cost-effectiveness analysis. 3 The number of family planning clients was 2846 between 1995 and 2000. This included 449 who were new family planning acceptors and 2397 who were previous users. The paper did not assess contraceptive use - focus was on cost-effectiveness. Using the outcome of couple years of protection (CYP) the analysis indicated that the intervention would produce family planning outcomes at no or low cost ($0.00 to $4.11). The cost per new acceptor ranged from $0.00 to $17.95. the paper concludes that providing financing to a for-profit company to provide family planning services can be a cost-effective way to increase new family planning acceptors. 36 Annex D Health and human rights standards Human Right Recommendations to States Relevant to Family Planning The Right to Consent to Marriage and to Equality in Marriage Ensure the right to “freely to choose a spouse and to enter into marriage only with their free and full consent” (1). Remove any requirements for spousal consent in order to access family planning services (2). The Right to Education “Family planning services should be situated within comprehensive sexual and reproductive health services and should encompass sexuality education, including counselling” (3). Ensure women’s rights “to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights” (4). Provide “access to specific educational information to help to ensure the health and well-being of families, including information and advice on family planning” (5). The Right to Equality and Non- Discrimination Take “all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning” (6). Ensure that states “take all appropriate measures to eliminate discrimination against disadvantaged women regarding access to health care, including family planning information, counselling, and services” (7). Ensure that states “report on measures taken to eliminate barriers that women face in gaining access to health care services and what measures they have taken to ensure women timely and affordable access to such services. Barriers include requirements or conditions that prejudice women‹s access such as high fees for health care services, the requirement for preliminary authorization by spouse, parent or hospital authorities, distance from health facilities and absence of convenient and affordable public transport ” )8.( “Ensure access to quality health care services” [including family planning], for all women, including adolescent girls, which are delivered in a way that “ensures that a woman gives her fully informed consent, respects her dignity, guarantees her confidentiality, and is sensitive to her needs and perspectives” (9). Ensure “the equal participation of women and men in all areas of household responsibilities, including family planning”… “should be promoted and encouraged by governments” (10). The Right to Health “Develop and implement programmes that provide access to sexual and reproductive health information and services, including for adolescents” (11). 37 Human Right Recommendations to States Relevant to Family Planning Ensure the availability, accessibility, acceptability and quality of family planning information and services (12). [Ensure that available family planning methods] “provide accessible, complete, and accurate information about various family planning methods, including their health risks and benefits, possible side effects and their effectiveness in the prevention of the spread of HIV/AIDS and other sexually transmitted diseases” (13). Ensure that “health facilities, goods and services [including family planning] must be accessible to all, especially the most vulnerable or marginalized sections of the population in law and in fact without discrimination on any of the prohibited grounds” (14). The Right to Information and Freedom of Expression “Ensure that women and men have information and access to the widest possible range of save and effective family-planning methods in order to enable them to exercise free and informed choice” (15). Provide accessible, comprehensive information on family planning to make options clear to individuals… “In order to make an informed decision about safe and reliable contraceptive measures, women must have information about contraceptive measures and their use, and guaranteed access to sex education and family planning services, as provided in article 10 (h) of the Convention” (16). The Right to Liberty and Security of Person Ensure that “no one shall be subjected to arbitrary or unlawful interference with privacy, family, home or correspondence”, [including in decisions relating to family planning] (17). Ensure “no one shall be subjected… to unlawful attacks on his honour and reputation” [for any decisions pertaining to family planning] (18). The Right to Life Ensure “the prevention of unwanted pregnancy through family planning and sex education and reduce maternal mortality rates through safe motherhood services and prenatal assistance” (19). The Right Not to be Subjected to Torture or Other Cruel, Inhuman, or Degrading Treatment or Punishment “Ensure that measures are taken to prevent coercion in regard to fertility and reproduction” (20). Ensure the “right to make decisions concerning reproduction” [including family planning] free of discrimination, coercion and violence, as expressed in human rights documents“ (21). The Right to Participate in the Conduct of Public Affairs and the Right to Ensure free, active and informed participation of individuals in decision-making related to family planning … “Reproductive health care programmes should be designed to serve the needs of women, including adolescents, and must involve women in the leadership, planning, decision-making, management, implementation, organization, and evaluation of services” (22). 38 Human Right Recommendations to States Relevant to Family Planning Free, Active and Meaningful Participation Ensure that “special efforts [are] made to emphasize men’s shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behaviour, including family planning…” (23) The Right to Privacy Ensure that “accessibility of information [will] not impair the right to have personal health data treated with confidentiality” [including information pertaining to family planning] (24). Ensure that “all health facilities, goods and services [including family planning] are “designed to respect confidentiality and improve the health status of those concerned” (25). “The realization of the right to health of adolescents is dependent on the development of youth-friendly health care, which respects confidentiality and privacy and includes appropriate sexual and reproductive health services” (26). The Right to Decide the Number and Spacing of Children Ensure the “same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights” (27). Ensure that “Compulsory sterilization or abortion” [pertaining to family planning does not occur as it] “adversely affects women’s physical and mental health, and infringes the right of women to decide on the number and spacing of their children” (28). Ensure that “decisions to have children or not, while preferably made in consultation with spouse or partner, must not” … ”be limited by spouse, parent, partner or Government” (29). The Right to be Free from Practices that Harm Women and Girls “Ensure that harmful social or traditional practices do not interfere with access to pre- and post-natal care and family-planning; to prevent third parties from coercing women to undergo traditional practices, e.g. female genital mutilation; and to take measures to protect all vulnerable or marginalized groups of society, in particular women, children, adolescents and older persons, in the light of gender-based expressions of violence” (30). The Right to be Free from Violence Ensure that states “take appropriate and effective measures to overcome all forms of gender-based violence,” [including sexual violence and all other forms of violence pertaining to family planning] (31). Ensure “the enactment and effective enforcement of laws and the formulation of policies, including health care protocols” [and family planning programs] “to address violence against women and abuse of girl children and the provision of appropriate health services” (32). “Undertake preventive, promotive and remedial action to shield women from the impact of harmful traditional cultural practices and norms that deny them their full reproductive rights (33). 39 1. CEDAW Convention on the Elimination of Violence Against Women. Article 16 (B). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 2. CEDAW General recommendation no. 21 Article 16 (1b) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 3. CRC General Comment no. 15 on the right of the child to the enjoyment of the highest attainable standard of health (art 24 of the International Convention on the Rights of the Child.) New York, UN Committee on the Rights of the Child, 2013. (UN Doc. CRC/C/GC/15) 4. CEDAW Convention on the Elimination of Violence Against Women. (Introduction). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 5. CEDAW Convention on the Elimination of Violence Against Women. Article 10 (h). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 6. CEDAW Convention on the Elimination of Violence Against Women. Article 12 (1). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 7. CEDAW General recommendation no. 21 Article 16 (1) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13h Session 1994. 8. General Comment no. 14 Article 12.2 (a). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 9. CEDAW General recommendation no. 24 Article12 (1) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 20th Session 1999. 10. Report of the International Conference on Population and Development. Chapter VII, Action 4.26. Cairo, 5-13 September 1994. 11. General Comment no. 14 Article 12.2 (a). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 12. CEDAW General recommendation no. 24 Article 12 (1) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 13. Report of the International Conference on Population and Development. Chapter VII, Action 7.23 (b). Cairo, 5-13 September 1994. 14. General Comment no. 14 Article 12. The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social, and Cultural Rights). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 15. Report of the International Conference on Population and Development. Chapter VII, Action 7.23 (a). Cairo, 5-13 September 1994. 16. CEDAW General recommendation no. 19 Article 16 (1)(e) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 11th Session 1992. 17. Article 17 of the International Covenant on Civil and Political Rights (CCPR). New York, UN Human Rights Committee, 1976. 18. See reference 17. 40 19. CEDAW General recommendations for government action no. 13 (c). International Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 20. CEDAW General recommendation no. 19 Article 16 (and 5) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 11th Session 1992. 21. Report of the International Conference on Population and Development. Chapter V, Action 7.7. Cairo, 5-13 September 1994. 22. Report of the International Conference on Population and Development. Chapter VII, Action 7.3. Cairo, 5-13 September 1994. 23. Report of the International Conference on Population and Development. Chapter VII, Action 4.27. Cairo, 5-13 September 1994. 24. General Comment no. 14 Article 12 (b). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 25. See reference 24. 26. General Comment no. 14 Article 12 (no. 23). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 27. CEDAW Convention on the Elimination of Violence Against Women. Article 16 (1) (e). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 1979. 28. See reference 19 29. See reference 27 30. General Comment no. 14, Specific Legal Obligation no. 34. The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 31. CEDAW General recommendation no. 19 Article 16 (and article 5) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 11th Session 1992. 32. CEDAW General recommendation no. 24 Article 12 (1) (12b) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 33. General Comment no. 14 Article 12 (no. 21). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4)
Sicherstellung der Menschenrechte bei der Bereitstellung von Informationen und Diensten im Bereich der Empfängnis verhütung Anhang A Leitliniensteuerungsgruppe Anhang B Leitlinienentwicklungsgruppe Anhang C Zusammenfassende GRADE-Einstufungs- und -Evidenztabellen Anhang D Gesundheitsstandards und Menschenrechtsnormen 2 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Impressum pro familia Bundesverband Mainzer Landstraße 250–254 60326 Frankfurt am Main E-Mail: info@profamilia.de www.profamilia.de/Publikationen © 2018 Weitere Auskünfte erteilt die: Department of Reproductive Health and Research Weltgesundheitsorganisation Avenue Appia 20, CH-1211 Genf 27, Schweiz Fax: +41 22 791 4171 E-Mail: reproductivehealth@who.int Titel-Foto: © yuliya_chitakh – fotolia.com Gefördert vom Die Originalausgabe dieses Werks erschien 2014 unter dem Titel Annexes: ensuring human rights in the provision of contraceptive information and services: guidance and recommendations © Weltgesundheitsorganisation 2014. Die deutsche Übersetzung erfolgte mit freundlicher Genehmigung der Weltgesundheitsorganisation durch Miriam Geoghegan. Der Herausgeber allein ist für die Richtigkeit der Übersetzung verantwortlich. 3 Inhaltsverzeichnis Anhang A Leitliniensteuerungsgruppe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Anhang B Leitlinienentwicklungsgruppe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Anhang C Zusammenfassende GRADE-Einstufungs- und -Evidenztabellen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Anhang D Gesundheitsstandards und Menschenrechtsnormen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 4 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Der Zugang zu Informationen und Diensten im Bereich der Empfängnisverhütung und der Familienplanung steht für pro familia im Rang eines Menschenrechts. Verschiedene internationale Vereinbarungen, die auch den hier vorgelegten übersetzten WHO-Papieren zu- grunde liegen, teilen dieses Verständnis. Sie haben das Recht auf Familienplanung seit Ende der 1990er Jahre im neuen Paradigma der sexuellen und reproduktiven Gesundheit und Rechte (SRGR) ausformuliert.1 Die vorliegenden WHO-Papiere wurden mit dem Ziel entwickelt, dazu beizutragen, den Zugang zu Informatio- nen und Diensten im Bereich der Empfängnisverhütung zu verbessern und dabei die Menschrechte zu achten, zu schützen und zu verwirklichen. Der Verdienst dieser Papiere ist es, die verschiedenen Dimensionen der Menschenrechte auf diesen Bereich angewendet und notwendige Anforderungen an Infor- mationen und Dienste im Bereich der Empfängnisver- hütung ausformuliert zu haben. Das Rahmenkonzept bietet wertvolle Ordnungsprinzipien und Normen, die zur Wahrung der Klient*innen-Rechte und zur Verwirk- lichung der sexuellen und reproduktiven Rechte für eine beraterische, psychosoziale und medizinische Praxis not- wendig sind. In den Leitlinien und Empfehlungen sowie den dazugehörigen Anhängen werden die wissenschaft- liche Systematik und die Konsequenzen für politische Strategien und Programme dargelegt. pro familia bedankt sich bei der WHO für die freundliche Genehmigung, eine deutsche Übersetzung der folgen- den drei Papiere vorzulegen: Vorwort zur deutschen Übersetzung ● Rahmenkonzept für die Sicherstellung der Menschen- rechte bei der Bereitstellung von Informationen und Diensten im Bereich der Empfängnisverhütung ● Sicherstellung der Menschenrechte bei der Bereitstel- lung von Informationen und Diensten im Bereich der Empfängnisverhütung – Leitlinien und Empfehlungen ● Sicherstellung der Menschenrechte bei der Bereit- stellung von Informationen und Diensten im Bereich der Empfängnisverhütung – Anhänge der Leitlinien und Empfehlungen Die Übersetzung dieser Papiere soll dazu beitragen, die wertvollen Erkenntnisse und Hinweise für politische Entscheidungsträger*innen, Fachverbände aus dem Bereich sexuelle und reproduktive Gesundheit sowie für Fachkräfte aus der psychosozialen Beratung und den Ge- sundheitsdiensten zugänglich zu machen. Sie erfolgt im Rahmen des Modellprojektes „biko-Beratung, Informa- tionen und Kostenübernahme bei Verhütung“, welches vom Bundesministerium für Familie, Senioren, Frauen und Jugend gefördert wird. Ein Ziel des Modellprojektes ist, eine gute Praxis zur Kostenübernahme mit niedrig- schwelliger Beratung und Information zu Verhütung für bedürftige Frauen zu erproben. pro familia Bundesverband 2018 1 Aktionsprogramm der Internationalen Konferenz zur Bevölkerung und Entwicklung in Kairo (1995), Charta der sexuellen und reproduk- tiven Rechte von der International Planned Parenthood Federation (1996), Sustainable-Development-Goals der Vereinten Nationen (2015) 5 Anhang A Leitliniensteuerungsgruppe Lynn Bakimajian Carmen Barroso Leo Bryant Jane Cottingham Nel Druce Lynn Freedman Sofia Gruskin Karen Hardee Jane Hobson Sandra Jordan Eszter Kismodi Jan Kumar Karen Newman Mariela Rodriguez Kate Shaw WHO-Mitarbeiterinnen und -Mitarbeiter Maria Rodriguez Monica Dragoman Rajat Khosla Lale Say Marleen Temmerman 6 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Anhang B Leitlinienentwicklungsgruppe Alfonso Barrangues UNFPA, USA Harriet Birungi Population Council, Kenia Shelah S. Bloom MEASURE Evaluation, University of North Carolina in Chapel Hill, USA Dirk Van Braeckel University of Ghent, Belgien Jacqueline Bryld Danish Family Planning Association Sex and Samfund, Dänemark Caroline Phiri Chibawe Mother and Child Health Ministry of Community Development, Sambia Jacqueline Darroch Guttmacher Institute, USA Suzanne Ehlers Population Action International, USA Faustina Fynn-Nyame Marie Stopes International Ghana, Ghana Christine Galavotti Sexual, Reproductive and Maternal Health CARE USA, USA Baochang Gu Center for Population and Development Studies Renmin University of China, China Demet Güral Technical and Program Strengthening Pathfinder International, USA Krishna Jafa Population Services International (PSI), Indien Sandra Jordan USAID, USA Jane Kiragu Satima Consultants Ltd, Kenia Sunita Kishor MEASURE DHS, USA Rebecca Koladycz International Planned Parenthood Federation, USA Tamara Kreinin Population and Reproductive Health Program The David and Lucile Packard Foundation, USA Matthew Lindley International Planned Parenthood Federation, Vereinigtes Königreich Nyovani J. Madise Social Statistics & Demography University of Southampton, Vereinigtes Königreich Tarek Meguid University of Namibia, School of Medicine, Namibia Poonam Mutreja Population Foundation of India, Indien Nuriye Ortayli Reproductive Health UNFPA, USA Jacqueline Pitanguy CEPIA, Brasilien Melanie Pleaner Wits Reproductive Health and HIV Research Institute Witwatersrand University, Südafrika Serge Rabier Equilibres & Populations, Frankreich Scott Radloff Bill & Melinda Gates Institute for Population and Reproductive Health, USA Sara Seims The David and Lucile Packard Foundation, Vereinigtes Königreich Saroj Kumar Sikdar Ministry of Health, Indien Sivananthi Thanenthiran The Asian-Pacific Resource & Research Centre for Women (ARROW), Malaysia Mountaga Toure The Malian Association for the Protection and Promotion of the Family, Mali Esther Vicente University of Puerto Rico, PROFAMILIA, Puerto Rico Senorina Wendoh International Planned Parenthood Federation, Vereinigtes Königreich 7 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Vo lle s In te rv en - tio ns pa ke t Pa rt ie lle s In te rv en tio ns - pa ke t Re la tiv (9 5 % C I) Ab so lu t Ve rh üt un gs er fa hr un g de r K lie nt in ne n un d Kl ie nt en 11 Be ob ac h tu ng ss tu di en er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –4 – – – se hr ni ed rig be de ut en d 0 % – 1 O ku el lo e t a l., 2 00 3 2 H oh es V er ze rr un gs ris ik o, d a un te rs ch ie dl ic he T ei ln eh m er in ne n be i d er B as is - u nd d er N ac hu nt er su ch un g be ur te ilt w ur de n. 3 O bw oh l d ie U ng en au ig ke it ni ch t s ch w er w ie ge nd w ar , w ar en e in ig e de r u nt er su ch te n G ru pp en (z um B ei sp ie l n eu e Kl ie nt in ne n) k le in (n <3 00 ). 4 D er V er hü tu ng se rf ah ru ng sw er t b ei n eu en K lie nt in ne n be tr ug 0 ,7 2 fü r d ie E xp er im en ta lg ru pp e (v ol le In te rv en tio n) u nd 0 ,7 1 fü r d ie K on tr ol lg ru pp e (p ar tie lle In te rv en tio n) , w as a uf e in en ge rin ge n U nt er sc hi ed z w is ch en d er v ol le n un d de r p ar tie lle n In te rv en tio n hi nd eu te t. 1. N ic ht di sk rim in ie ru ng D ie se E m pf eh lu ng b er uh t a uf M en sc he nr ec ht sn or m en (A nh an g D ). D ah er w ur de k ei ne g es un dh ei ts be zo ge ne E vi de nz g es uc ht . 2. V er fü gb ar be it Em pf eh lu ng 2 .1 In te gr at io n de r V er so rg un gs ke tt e D at um : 1 1. A pr il 20 13 Fr ag e: S ol lte d as v ol le In te rv en tio ns pa ke t ( vs . d as p ar tie lle In te rv en tio ns pa ke t) e in ge se tz t w er de n, u m d ie Q ua lit ät d er F am ili en pl an un gs di en st e zu v er be ss er n? Se tt in gs : U ga nd a Bi bl io gr ap hi e: An ha ng C Zu sa m m en fa ss en de G RA D E- Ei ns tu fu ng s- u nd -E vi de nz ta be lle n 8 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Th eo rie ba si er - te s M eh rk om - po ne nt en - pr og ra m m fü r Se xu al au f- kl är un g Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ko nd om be nu tz un g be im le tz te n G es ch le ch ts ve rk eh r ( er fa ss t m it te ls : B ef ra gu ng ) 11 ra nd om i si er te St ud ie n se hr h oc h2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e – – O R 1, 68 (1 ,0 2 bi s 2, 76 )3 – ni ed rig be de ut en d 0 % – 1 Co yl e et a l., 2 00 1 2 H oh es V er ze rr un gs ris ik o, w ei l e rs te ns d ie E nd pu nk tv ar ia bl en v on d en T ei ln eh m en de n se lb st b er ic ht et w ur de n, z w ei te ns e s k ei ne M ög lic hk ei t g ab , A us fä lle b ei d er N ac hb ef ra gu ng zu b er üc k- si ch tig en u nd d rit te ns k ei ne s ta tis tis ch e Ko rr ek tu r f ür m eh rf ac he S ig ni fik an zt es ts v or ge no m m en w ur de . D er B ei tr ag a rg um en tie rt , d as s d ie A na ly se n si ch a uf p rim är e un d se ku nd är e H yp o- th es en b es ch rä nk te n un d da ss a lle a nd er en T es ts a ls e xp lo ra to ris ch b et ra ch te t w ur de n. 3 D as O dd s R at io (O R; C ha nc en ve rh äl tn is) b er uh t a uf e in er M eh re be ne na na ly se m ith ilf e lo gi st is ch er o de r l in ea re r R eg re ss io n (d ie fü r d ie se n En dp un kt v er w en de te R eg re ss io ns ar t w ird n ic ht an ge ge be n) . D ie K on do m be nu tz un g be im le tz te n G es ch le ch ts ve rk eh r w ar e in s ek un dä re r E nd pu nk t d er S tu di e; d ie p rim är en E nd pu nk te w ar en d ie H äu fig ke it de s G es ch le ch ts ve rk eh rs o hn e Ko nd om u nd d ie A nz ah l d er S ex ua lp ar tn er in ne n be zi eh un gs w ei se S ex ua lp ar tn er . 3. Z ug än gl ic hk ei t 3. 1 U m fa ss en de S ex ua la ufk lä ru ng Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte e in th eo rie ba si er te s M eh rk om po ne nt en pr og ra m m fü r S ex ua la ufk lä ru ng b ei S ch ül er in ne n un d Sc hü le rn d er 9 . b is 1 2. K la ss e [h ig h sc ho ol ] e in ge se tz t w er de n? Se tt in gs : U SA – K al ifo rn ie n un d Te xa s Bi bl io gr ap hi e: 9 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Le hr pl an a uf B as is de r s oz ia l-k og - ni tiv en L er nt he or ie un d de r s oz ia le n In ok ul at io ns th eo rie Ko nt ro lle Re la tiv (9 5% CI ) Ab so lu t Be nu tz un g ei ne s K on do m s b ei m le tz te n G es ch le ch ts ve rk eh r ( er fa ss t m it te ls : B ef ra gu ng ) 11 ra nd om i si er te St ud ie n se hr h oc h2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – – – ni ed rig be de ut en d 0 % – 1 Co yl e et a l., 2 00 4 2 H oh es V er ze rr un gs ris ik o au fg ru nd (a ) d es E in sa tz es v on B ef ra gu ng en a uf d er B as is v on S el bs tb er ic ht en , u m E nd pu nk te zu b eu rt ei le n, (b ) d er m an ge ln de n Te iln ah m e vo n Sc hü le rin ne n un d Sc hü le rn , d ie e in e Te iln ah m ee rla ub ni s h at te n un d (c ) d er h oh en A us fä lle b ei d er N ac hb ef ra gu ng v on T ei ln eh m er in ne n od er T ei ln eh m er n. Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte e in L eh rp la n au f B as is d er s oz ia lk og ni tiv en L er nt he or ie u nd d er s oz ia le n In ok ul at io ns th eo rie b ei S ch ül er in ne n un d Sc hü le rn d er K la ss en 6 b is 9 e in ge se tz t w er de n? Se tt in gs : U SA – K al ifo rn ie n Bi bl io gr ap hi e: 10 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en M od el l g es un dh ei t- lic he r Ü be rz eu gu n- ge n in V er bi nd un g m it de r T he or ie so zi al en L er ne ns Ko nt ro lle Re la tiv (9 5% CI ) Ab so lu t Ve rh üt un gs effi zi en z (g ew ic ht et er , a us m eh re re n In di ka to re n zu sa m m en ge se tz te r I nd ex z ur B ew er tu ng d er K on se qu en z, m it de r J ug en dl ic he w irk sa m e M et ho de n de r E m pf än gn is - ve rh üt un g vo r u nd n ac h de r I nt er ve nt io n an w en de te n) ( er fa ss t m it te ls : B ef ra gu ng ) 12 Be ob ac h tu ng ss tu di en er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t 4 ke in e – – – – se hr ni ed rig be de ut en d 0 % – Ve rw en du ng e in es w irk sa m en V er hü tu ng sm it te ls b ei m le tz te n G es ch le ch ts ve rk eh r ( er fa ss t m it te ls : B ef ra gu ng ) 12 Be ob ac h tu ng ss tu di en er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t 4 ke in e –6 – – – se hr ni ed rig be de ut en d 0 % 1 D as P ro gr am m u m fa ss te v ie r B er ei ch e: S ac hi nf or m at io ne n, G ru pp en di sk us si on ü be r S ac hi nf or m at io ne n, G ru pp en di sk us si on ü be r W er te , G ef üh le u nd E m ot io ne n so w ie e in e D is ku ss io n üb er En ts ch ei du ng sfi nd un g un d pe rs ön lic he V er an tw or tu ng fü r d as e ig en e Se xu al ve rh al te n. 2 Ei se n (1 99 0) 3 Le di gl ic h 60 P ro ze nt d er B as is st ic hp ro be n ah m en a n de r F ol ge be fr ag un g na ch e in em Ja hr te il un d sc hl os se n di es e au ch a b. 4 Ei ni ge A na ly se n be ru ht en a uf k le in en U nt er gr up pe n de r G es am ts tic hp ro be (n =8 1) ; d ie H au pt an al ys en u m fa ss te n le di gl ic h 60 P ro ze nt d er P er so ne n, d ie d ie F ol ge be fr ag un g ab ge sc hl os se n ha be n. 5 Be i d en m än nl ic he n Be fr ag te n er ga b di e Fo lg eb ef ra gu ng n ac h ei ne m Ja hr k ei ne n st at is tis ch si gn ifi ka nt en U nt er sc hi ed b ei d er V er hü tu ng se ffi zi en z. B ei d en w ei bl ic he n Be fr ag te n ga b es e in en st at is tis ch si gn ifi ka nt en V or te il zu gu ns te n de r K on tr ol lg ru pp e: B ei d er In te rv en tio ns gr up pe b et ru g de r V er hü tu ng se ffi zi en zw er t 6 ,9 5; b ei d er K on tr ol lg ru pp e be lie f s ic h de r W er t a uf 1 2, 00 (p <0 .0 1) ; e in h öh er er W er t i st b es se r. 6 Be i d en m än nl ic he n Be fr ag te n w ar d ie A nw en du ng w irk sa m er V er hü tu ng m it 65 P ro ze nt in d er K on tr ol lg ru pp e hö he r a ls in d er In te rv en tio ns gr up pe (5 5 Pr oz en t). B ei d en w ei bl ic he n Be fr ag te n be ric ht et en 3 5 Pr oz en t d er T ei ln eh m er in ne n de r I nt er ve nt io ns gr up pe , d as s s ie w irk sa m e Ve rh üt un gs m it te l b ei m le tz te n G es ch le ch ts ve rk eh r v er w en de t h ät te n, v er gl ic he n m it 65 P ro ze nt d er Te iln eh m er in ne n de r K on tr ol lg ru pp e. Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte d as M od el l g es un dh ei tli ch er Ü be rz eu gu ng en (h ea lth b el ie f m od el ) i n Ve rb in du ng m it de r T he or ie s oz ia le n Le rn en s b ei Ju ge nd lic he n im A lte r vo n 13 b is 1 9 Ja hr en e in ge se tz t w er de n? 1 Se tt in gs : U SA – K al ifo rn ie n un d Te xa s Bi bl io gr ap hi e: 11 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Pe er ge le ite te Se xu al - au fk lä ru ng Le hr kr af t g el ei te te Se xu al au fk lä ru ng Re la tiv (9 5 % CI ) Ab so lu t Ve rh üt un gs m it te l b ei m e rs te n Se x ve rw en de t – w ei bl ic h (e rf as st d ur ch : F ra ge bo ge n) 11 ra nd om i si er te St ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – O R 0, 90 (0 ,7 3 bi s 1, 11 )3 – m od er at be de ut en d 0 % – Ve rh üt un gs m it te l b ei m e rs te n Se x – m än nl ic h (e rf as st d ur ch : F ra ge bo ge n) 12 ra nd om i si er te St ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – O R 1, 01 (0 ,6 8 bi s 1, 49 )3 – m od er at be de ut en d 0 % – 1 St ep he ns on e t a l., 2 00 4 2b E in g ew is se s V er ze rr un gs ris ik o be st eh t, da d ie E nd pu nk te v on d en B ef ra gt en s el bs t b er ic ht et w ur de n. D er B ei tr ag s te llt fe st , d as s e in e rh eb lic he s V er ze rr un gs ris ik o un w ah rs ch ei nl ic h se i. Es w ird je do ch k ei ne B eg rü nd un g fü r d ie se B eh au pt un g ge lie fe rt . 3 Im B ei tr ag w er de n de r S tic hp ro be nu m fa ng [n ] u nd d er P ro ze nt sa tz d er B ef ra gt en , d ie b ei m e rs te n Se x Ve rh üt un g an w en de te n, a ng eg eb en ; d ie G ru nd ge sa m th ei t [ G es am t- N ] w ird je do ch n ic ht an ge ge be n. D ie W eb se ite n m it de n zu sä tz lic he n Ta be lle n, a uf d ie im B ei tr ag v er w ie se n w ird (u nd d ie m ög lic he rw ei se d en G es am t- N b er ic ht et en ) s in d ni ch t m eh r v er fü gb ar . D ah er k on nt en ke in e An te ile in G RA D E ei ng eg eb en w er de n. Au to rin : P . W hy te D at um : 1 0. A pr il 2 01 3 Fr ag e: S ol lte p ee r-g el ei te te v s. le hr kr af tg el ei te te S ex ua la ufk lä ru ng b ei S ch ül er in ne n un d Sc hü le rn d er 9 . b is 1 2. K la ss e [h ig h sc ho ol ] e in ge se tz t w er de n? Se tt in gs : V er ei ni gt es K ön ig re ic h Bi bl io gr ap hi e: 12 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Pe er ge le ite te Se xu al - au fk lä ru ng Le hr kr af t g el ei te te Se xu al au fk lä ru ng Re la tiv (9 5 % CI ) Ab so lu t Ve rh üt un gs m it te l b ei m e rs te n Se x ve rw en de t – w ei bl ic h (e rf as st d ur ch : F ra ge bo ge n) 11 ra nd om i si er te St ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – O R 1, 07 (0 ,8 8 bi s 1, 31 )3 – m od er at be de ut en d 0 % – Ve rh üt un gs m it te l b ei m e rs te n Se x – m än nl ic h (e rf as st d ur ch : F ra ge bo ge n) 11 ra nd om i si er te St ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – O R 1, 04 (0 ,6 5 bi s 1, 68 )3 – m od er at be de ut en d 0 % – Ve rh üt un gs m it te l b ei m le tz te n G es ch le ch ts ve rk eh r – w ei bl ic h (e rf as st d ur ch : F ra ge bo ge n) 11 ra nd om i si er te St ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – O R 1, 57 (1 ,0 8 bi s 2, 29 )3 – m od er at be de ut en d 0 % – Ve rh üt un gs m it te l b ei m le tz te n G es ch le ch ts ve rk eh r – m än nl ic h (e rf as st d ur ch : F ra ge bo ge n) 11 ra nd om i si er te St ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – O R 0, 66 (0 ,3 1 bi s 1, 39 )3 – m od er at be de ut en d 0 % – 1 St ep he ns on e t a l., 2 00 8 2 Ei n ge w is se s V er ze rr un gs ris ik o be st eh t, da d ie E nd pu nk te v on d en B ef ra gt en s el bs t b er ic ht et w ur de n. 3 Im B ei tr ag w er de n fü r d ie In te rv en tio ns gr up pe u nd d ie K on tr ol lg ru pp e de r S tic hp ro be nu m fa ng [n ] u nd d er P ro ze nt sa tz d er B ef ra gt en , d ie b ei m e rs te n Se x Ve rh üt un g an w en de te n, a ng eg eb en ; di e G ru nd ge sa m th ei t [ G es am t- N ] f ür je de G ru pp e w ird je do ch n ic ht a ng eg eb en . D ah er k on nt en A nt ei le n ic ht in G RA D E ei ng eg eb en w er de n Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte p ee r-g el ei te te o de r l eh rk ra ft ge le ite te S ex ua la ufk lä ru ng b ei S ch ül er in ne n un d Sc hü le rn 9 . b is 1 2. K la ss e [h ig h sc ho ol ] e in ge se tz t w er de n? Se tt in gs : V er ei ni gt es K ön ig re ic h Bi bl io gr ap hi e: 13 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Ve rh üt un gs - m et ho de de r W ah l ko st en fr ei Ko nt ro lle Re la tiv (9 5% C I) Ab so lu t An w en du ng e in er L an gz ei tv er hü tu ng sm et ho de 12 Be ob ac h tu ng s st ud ie n er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –4 – – – se hr ni ed rig be de ut en d 0 % – 1 Ei n Ve rg le ic h m it de r k os te np fli ch tig en V er w en du ng v on V er hü tu ng sm it te ln fa nd n ic ht s ta tt . 2 Se cu ra e t a l., 2 01 0 3 Be ob ac ht un gs st ud ie , d ie n ur d en A nt ei l d er F ra ue n an gi bt , d ie si ch fü r V er hü tu ng e nt sc hi ed en h ab en . 4 D ie S tu di e be ric ht et e le di gl ic h, d as s 6 7 Pr oz en t d er F ra ue n si ch fü r L an gz ei tv er hü tu ng sm et ho de n en ts ch ie de n hä tt en ; 2 50 0 Fr au en w ur de n in d ie S tu di e au fg en om m en ; e s w ur de n ke in e An ga be n ge m ac ht ü be r d ie A nz ah l d er F ra ue n, d ie b ef ra gt w ur de n. Em pf eh lu ng 3 .2 B es ei tig un g fin an zi el le r H in de rn is se Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte n Fr au en im G ro ßr au m S t. Lo ui s d ie V er hü tu ng sm et ho de ih re r W ah l k os te nf re i a nw en de n [k ön ne n] ?1 Se tt in gs : U SA Bi bl io gr ap hi e: 14 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Ke in e In te rv en tio n Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ko nd om nu tz un g be im le tz te n G es ch le ch ts ve rk eh r ( er fa ss t m it te ls B ef ra gu ng ) 12 Be ob ac h tu ng s st ud ie n er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –4 – – – se hr ni ed rig be de ut en d 0 % – Be re it st el lu ng v on G ra tis ko nd om en (e rf as st m it te ls B ef ra gu ng ) 12 Be ob ac h tu ng s st ud ie n er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –4 – O R 1, 98 (1 ,0 8 bi s 3, 61 )5 – se hr ni ed rig be de ut en d 0 % – 1 Be i d ie se r S tu di e w ur de k ei ne In te rv en tio n ei ng es et zt . E s w ur de v ie lm eh r d ie a kt ue lle K on do m nu tz un g be i m än nl ic he n H oc hs ch ul st ud en te n un te rs uc ht . 2 Lo ng e t a l., 2 01 2 3 D er B ei tr ag b er ic ht et , d as s d ie S tu di e le di gl ic h ei ne k le in e An za hl v on H oc hs ch ul st ud en te n um fa ss t h ab e un d da ss d ie E rg eb ni ss e da he r m ög lic he rw ei se n ic ht re pr äs en ta tiv s ei en . D ie E rg eb ni ss e be ru he n zu de m a uf re tr os pe kt iv en D at en , o bw oh l d ie K on do m nu tz un g am b es te n an ha nd v on T ag es ka le nd er n er fa ss t w er de n ka nn . 4 D er B ei tr ag b er ic ht et le di gl ic h, d as s 6 1, 5 Pr oz en t d er B ef ra gt en e in K on do m b ei m le tz te n G es ch le ch ts ve rk eh r b en ut zt h ät te n. E s w er de n ke in e N [G ru nd ge sa m th ei te n] a ng eg eb en . 5 O dd s R at io [O R; C ha nc en ve rh äl tn is] f ür K on do m be nu tz un g, w en n G ra tis ko nd om e ve rf üg ba r w ar en . W en n ko st en lo se B er at un g üb er re pr od uk tiv e G es un dh ei t b er ei tg es te llt w ur de , b et ru g da s Ch an ce nv er hä ltn is fü r d ie K on do m nu tz un g 1, 54 (9 5 Pr oz en t C I: 1, 08 , 2 ,7 4) v er gl ic he n m it „k ei ne B er at un g“ . Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte k ei ne In te rv en tio n be i m än nl ic he n H oc hs ch ul st ud en te n ei ng es et zt w er de n? 1 Se tt in gs : C hi na Bi bl io gr ap hi e: 15 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Ve rh üt un gs - m et ho de de r W ah l ko st en fr ei Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t An w en du ng e in er L an gz ei tv er hü tu ng sm et ho de 12 Be ob ac h tu ng s st ud ie n er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –4 – – – se hr ni ed rig be de ut en d 0 % – 1 Be i d ie se r S tu di e w ird k ei n Ve rg le ic h m it de r V er w en du ng v on k os te np fli ch tig en V er hü tu ng sm it te ln v or ge no m m en . 2 Pe ip er t e t a l., 2 01 2 3 Be ob ac ht un gs st ud ie , d ie le di gl ic h de n An te il de r B ef ra gt en a ng ib t, di e ei ne L an gz ei tv er hü tu ng sm et ho de a nw en de te n. 4 D er B ei tr ag b er ic ht et , d as s 7 5 Pr oz en t d er B et ei lig te n si ch fü r e in e La ng ze it ve rh üt un gs m et ho de e nt sc hi ed en h ät te n. E s h an de lt si ch u m e in e Fo lg es tu di e de r i n Se cu ra e t a l. (2 01 0) b er ic ht et en U nt er su ch un g. S ec ur a et a l. (2 01 0) b er ic ht et en , d as s 6 7 Pr oz en t d er e rs te n 25 00 T ei ln eh m er in ne n si ch fü r e in e La ng ze it ve rh üt un gs m et ho de e nt sc hi ed en h ät te n. D ie p rim är en E nd pu nk te w ar en Sc hw an ge rs ch af ts ab br üc he , e rn eu te S ch w an ge rs ch af ts ab br üc he u nd G eb ur te n im T ee na ge al te r. Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte n Fr au en im G ro ßr au m S t. Lo ui s d ie V er hü tu ng sm et ho de ih re r W ah l k os te nf re i a nw en de n [k ön ne n] ?1 Se tt in gs : U SA Bi bl io gr ap hi e: 16 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Pr og ra m m m it w ei bl ic he m G es un dh ei ts - pe rs on al Ke in P ro - gr am m Re la tiv (9 5% C I) Ab so lu t An w en du ng e in er m od er ne n re ve rs ib le n Ve rh üt un gs m et ho de (e rf as st m it te ls : B ef ra gu ng ) 12 Be ob ac h tu ng s st ud ie n3 er ns th af t4 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –4 – O R 1, 50 (1 ,0 4 bi s 2, 16 )5 – se hr ni ed rig be de ut en d 0 % – 1 W ei bl ic he s G es un dh ei ts pe rs on al s te llt e G es un dh ei ts di en st e fü r M üt te r u nd K in de r b er ei t. 2 D ou th w ai te u nd W ar d, 2 00 2 3 Re tr os pe kt iv e D at en an al ys e. 4 H oh es V er ze rr un gs ris ik o, d a es si ch u m e in e Be ob ac ht un gs st ud ie h an de lte u nd k ei ne B as is da te n er ho be n w ur de n. 5 Be ru ht a uf e in er m ul tiv ar ia te n lo gi st is ch en R eg re ss io ns an al ys e. D er B ei tr ag li ef er t l ed ig lic h Pr oz en ts ät ze (k ei ne G ru nd ge sa m th ei te n [N ]) fü r d ie In te rv en tio ns gr up pe u nd d ie K on tr ol lg ru pp e fü r de n An te il de r B ef ra gt en , d ie m od er ne re ve rs ib le V er hü tu ng sm et ho de n an w en de te n. Em pf eh lu ng 3 .3 V er be ss er un g de s Z ug an gs fü r B ev öl ke ru ng sg ru pp en , d ie S ch w ie rig ke ite n be im Z ug an g zu D ie ns te n ha be n (E vi de nz fü r l än dl ic he B ev öl ke ru ng ) Au to rin : P . W hy te D at um : 2 0. M är z 20 13 Fr ag e: S ol lte e in v on w ei bl ic he m G es un dh ei ts pe rs on al b er ei tg es te llt es P ro gr am m v s. ke in P ro gr am m b ei v er he ira te te n Fr au en e ig es et zt w er de n? 1 Se tt in gs : P ak is ta n Bi bl io gr ap hi e: 17 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be re it st el lu ng vo n Fa m ili en - pl an un gs di en st en du rc h tr ad iti on el le M ed iz in er in ne n un d M ed iz in er Ko nt - ro lle Re la tiv (9 5 % CI ) Ab so lu t An w en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 11 Be ob ac h tu ng s st ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e 50 8/ 80 0 (6 3, 5% )3 41 3/ 85 0 (4 8, 6 % ) – 48 6 w en ig er pr o 10 00 (v on 4 86 w en ig er b is 48 6 w en ig er ) se hr ni ed rig be de ut en d 0 % – 1 Ka m bo 2 Be ob ac ht un gs st ud ie ; d ie e in be zo ge ne n G eb ie te w ur de n „g ez ie lt “ a us ge w äh lt . 3 Zw is ch en d em B eg in n de r S tu di e un d de r F ol ge un te rs uc hu ng w ar d er A ns tie g be i d er V er w en du ng v on V er hü tu ng sm it te ln im V er gl ei ch zu r K on tr ol lg ru pp e hö he r. D ie h ie r d ar ge st el lte n W er te si nd d ie d er F ol ge un te rs uc hu ng . Au to rin : P . W hy te D at um : 2 0. M är z 20 13 Fr ag e: S ol lte n tr ad iti on el le M ed iz in er in ne n un d M ed iz in er e in ge se tz t w er de n, u m F am ili en pl an un gs di en st e fü r l än dl ic he B ev öl ke ru ng en b er ei tz us te lle n? Se tt in gs : U tt ar P ra de sh , B ez irk M uz aff am ag ar (I nd ie n) Bi bl io gr ap hi e: 18 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be re it st el lu ng ve rb es se rt er G es un dh ei ts di en st e Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t An w en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 11 Be ob ac h tu ng s st ud ie n2 er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e – – –4 – se hr ni ed rig be de ut en d 0 % – 1 Ka te nd e et a l., 2 00 3 2 Re tr os pe kt iv e D at en an al ys e. 3 H oh es V er ze rr un gs ris ik o, d a di e An al ys e si ch a uf e in ric ht un gs ba si er te n In fo rm at io ne n be sc hr än kt e un d an de re p ro gr am m at is ch e In te rv en tio ne n ni ch t b er üc ks ic ht ig t w ur de n, d ie m ög lic he r- w ei se e in en E ff ek t h at te n. 4 D er B ei tr ag b er ic ht et , d as s k ei ne d er M aß st äb e fü r d ie B er ei ts te llu ng v on D ie ns te n si gn ifi ka nt m it de r A nw en du ng v on m od er ne n Ve rh üt un gs m et ho de n be i F ra ue n, d ie in lä nd lic he n G eb ie te n le bt en , k or re lie rt e. Au to rin : P . W hy te D at um : 2 0. M är z 20 13 Fr ag e: S ol lte n ve rb es se rt e G es un dh ei ts di en st e fü r d ie lä nd lic he B ev öl ke ru ng b er ei tg es te llt w er de n? Se tt in gs : U ga nd a Bi bl io gr ap hi e: 19 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en G em ei nd en ah er An sa tz Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t An w en du ng m od er ne r M et ho de n re ve rs ib le r V er hü tu ng (e rf as st m it te ls : B ef ra gu ng ) 11 Be ob ac h tu ng s st ud ie n2 er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e – – O R 1, 74 (1 ,1 1 bi s 2, 71 )4 – se hr ni ed rig be de ut en d 0 % – 1 Su lta n et a l., 2 00 2 2 Re tr os pe kt iv e An al ys e vo n U m fr ag ed at en . 3 Re tr os pe kt iv e D at en an al ys e; d ie M ög lic hk ei t, ei ne V er bi nd un g zw is ch en k au sa le n Fa kt or en h er zu st el le n, is t d ah er b eg re nz t. 4 Be re in ig te s O dd s R at io (O R; C ha nc en ve rh äl tn is) z ei gt , d as s b ei F ra ue n, d ie h öc hs te ns 5 k m v on z w ei G em ei nd ea rb ei te rin ne n bz w . G em ei nd ea rb ei te rn e nt fe rn t l eb te n, d ie W ah rs ch ei nl ic hk ei t d er An w en du ng m od er ne r V er hü tu ng sm et ho de n si gn ifi ka nt h öh er w ar a ls b ei F ra ue n, d ie k ei ne n Zu ga ng zu G em ei nd ea rb ei te rin ne n bz w . - ar be ite rn h at te n Au to rin : P . W hy te D at um : 2 0. M är z 20 13 Fr ag e: S ol lte e in g em ei nd en ah er A ns at z be i e in er lä nd lic he n Be vö lk er un g an ge w en de t w er de n? Se tt in gs : P ak is ta n Bi bl io gr ap hi e: 20 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en G em ei nd en ah e An bi et er in ei ne m N ot fa ll- se tt in g Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t An w en du ng m od er ne r V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 12 Be ob ac h tu ng s st ud ie n ke in er ns th af te s Ve rz er ru ng s ris ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e 10 70 /2 37 7 (4 5 % )2 – Pr äv al en z ra te Ve rh äl tn is 1, 88 (1 ,6 3 bi s 2, 17 )3 – ni ed rig be de ut en d 0 % – 1 M ul la ny e t a l., 2 01 0 2 Es h an de lt si ch u m d en A nt ei l d er B ef ra gt en , d ie a m E nd e de r I nt er ve nt io n m od er ne V er hü tu ng sm et ho de n an w en de te n. D er A nt ei l d er B ef ra gt en , d ie m od er ne V er hü tu ng sm et ho de n zu B eg in n de r I nt er ve nt io n an w en de te n be tr ug 2 3, 9 Pr oz en t. 3 Ve rg le ic h zw is ch en B eg in n un d En de d er In te rv en tio n Em pf eh lu ng 3 .4 V er tr ie be ne B ev öl ke ru ng sg ru pp en Au to rin : P . W hy te D at um : 2 8. M är z 20 13 Fr ag e: S ol lte n ge m ei nd en ah e An bi et er in e in em N ot fa lls et tin g be i F lü ch tli ng sg ru pp en e in ge se tz t w er de n? Se tt in gs : O st bu rm a Bi bl io gr ap hi e: 21 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua li- tä t Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en In te gr at io n vo n H IV / AI D S- D ie ns te n in G es un d- he it sd ie ns te fü r M üt te r, N eu ge bo re ne u nd K in de r so w ie in E rn äh ru ng s- u nd Fa m ili en pl an un gs di en st e Ko n- tr ol le Re la tiv (9 5 % C I) Ab so lu t An w en du ng v on V er hü tu ng (Ä th io pi en ) 13 ,4 Be ob ac h tu ng s st ud ie n se hr er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e 21 2/ 33 74 (6 ,3 % )6 – – – se hr ni ed rig be de ut en d 0 % – An w en du ng v on V er hü tu ng (Ä th io pi en ) 13 ,7 Be ob ac h tu ng s st ud ie n se hr er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e 47 4/ 67 7 (7 0 % )6 ,8 – – – se hr ni ed rig be de ut en d 0 % – An w en du ng v on V er hü tu ng (M al aw i; H IV -p os iti ve F ra ue n) 13 ,9 Be ob ac h tu ng s st ud ie n se hr er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t1 0 ke in e 92 /2 00 (4 6 % )6 ,1 1 – – – se hr ni ed rig be de ut en d 0 % – Pa ar ve rh üt un gs ja hr e (C YP ) b er ec hn et , i nd em d ie m en ge nm äß ig e G es am tn ut zu ng v on je de m F am ili en pl an un gs pr od uk t d ur ch d ie D au er d es a ng eb ot en en S ch ut ze s g et ei lt w ird , un te r A nn ah m e ei ne s D ur ch sc hn it ts v on 10 H an dl un ge n pr o M on at (N ig er ia ) 13 ,1 2 Be ob ac h tu ng s st ud ie n se hr er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –1 3 – – – se hr ni ed rig be de ut en d 0 % – An w en du ng v on V er hü tu ng (K en ia ) 13 ,1 4 Be ob ac h tu ng s st ud ie n se hr er ns th af t1 5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –6 – – – se hr ni ed rig be de ut en d 0 % – An w en du ng v on V er hü tu ng (T an sa ni a) 13 ,1 7 Be ob ac h tu ng s st ud ie n se hr er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e 17 2/ 40 7 (4 2, 3 % ) – O R 1, 23 (0 ,8 7 bi s 1. 72 )1 ,8 – se hr ni ed rig be de ut en d 0 % – Em pf eh lu ng 3 .5 In te gr at io n vo n H IV /A ID S- D ie ns te n Au to rin : P . W hy te D at um : 5 . M är z 20 13 Fr ag e: S ol lte n H IV /A ID S- D ie ns te z w ec ks B ek äm pf un g de r M üt te r- un d Ki nd er st er bl ic hk ei t u nd d er K on tr ol le d er H IV /A ID S- Ep id em ie in G es un dh ei ts di en st e fü r M üt te r, N eu ge bo re ne u nd K in de r s ow ie in E rn äh ru ng s- u nd F am ili en pl an un gs di en st e in te gr ie rt w er de n? 1 Se tt in gs : A lle L än de r2 Bi bl io gr ap hi e: Li nd eg re n et a l., 2 01 2 22 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung 1 Es h an de lt si ch u m d as G es un dh ei ts pr ob le m , d as in d er s ys te m at is ch en Ü be rs ic ht sa rb ei t i de nt ifi zi er t w ur de . D ie F ra ge st el lu ng , z u de r d ie se s P ro bl em in d er Ü be rs ic ht sa rb ei t g eh ör te , l au te te : „G ib t e s I nt er ve nt io ne n, d ie si ch im V er gl ei ch zu r A us ga ng sv er so rg un g („ ke in e In te rv en tio n“ ) a ls w irk sa m e rw ie se n, e in en g er ec ht en Z ug an g zu In fo rm at io ne n un d D ie ns te n im B er ei ch d er Fa m ili en pl an un g fü r ( po te nz ie lle ) N ut ze rin ne n un d N ut ze r z u ve rb es se rn ? D ie e nt sp re ch en de F or sc hu ng sf ra ge la ut et e: „G ib t e s B el eg e da fü r, da ss d ie In te gr at io n vo n H IV -D ie ns te n di e Zu gä ng - lic hk ei t v on F am ili en pl an un gs di en st en v er be ss er t? “. 2 D ie Ü be rs ic ht sa rb ei t v on L in de gr en e t a l. (2 01 2) u m fa ss te L än de r m it ho he m , m it tle re m u nd n ie dr ig em E in ko m m en n ac h de r D efi ni tio n de r W el tb an k. D ie S tu di en , d ie ü be r d ie V er w en du ng v on Ve rh üt un gs m it te ln b er ic ht et en , w ur de n in L än de rn m it ni ed rig em u nd m it tle re n Ei nk om m en d ur ch ge fü hr t. 3 D ie Ü be rs ic ht sa rb ei t v on L in de gr en e t a l. (2 01 2) s te llt fe st , d as s s ie be n de r 1 9 in d er Ü be rs ic ht sa rb ei t b er üc ks ic ht ig te n St ud ie n üb er d ie V er w en du ng v on V er hü tu ng sm it te ln b er ic ht et en . A n- ge si ch ts d er T at sa ch e, d as s d ie Ü be rs ic ht sa rb ei t k ei ne D at en a us d ie se n St ud ie n en th äl t, so nd er n le di gl ic h fe st st el lt, d as s a lle si eb en S tu di en , d ie ü be r d ie V er w en du ng v on V er hü tu ng sm it te ln be ric ht et en , p os iti ve E rg eb ni ss e er zi el t u nd b er ic ht et h ät te n, d as s d ie A nw en du ng v on F am ili en pl an un g (s ow oh l K on do m -M et ho de n al s a uc h N ic ht -K on do m -M et ho de n) a ng es tie ge n se i, w ird di e vo rli eg en de G RA D E- Ta be lle ü be r j ed e de r v er fü gb ar en S tu di en e in ze ln b er ic ht en . Z w ei d er z iti er te n St ud ie n (B ro u et a l., 2 00 9 un d Ki ng e t a l., 1 99 5) w ar en n ic ht v er fü gb ar . D a ke in e Er ge bn is se in d er Ü be rs ic ht sa rb ei t v on L in de gr en e t a l. (2 01 2) b er ic ht et w ur de n, w er de n ke in e Er ge bn is se a us d ie se n be id en S tu di en h ie r a uf ge fü hr t. 4 Br ad le y et a l., 2 00 9 5 H oh es R is ik o de r S tic hp ro be nv er ze rr un g; m an ge ls V er bl in du ng w ar d as R is ik o de r V er ze rr un g au fg ru nd v on u nt er sc hi ed lic he n Be ha nd lu ng en h oc h; d a al le E nd pu nk te v on d en B ef ra gt en s el bs t be ric ht et w ur de n, w ar d as R is ik o de r V er ze rr un g au fg ru nd v on s el ek tiv em B er ic ht en e be nf al ls h oc h. 6 Es h an de lt si ch u m d en k om bi ni er te n W er t f ür M än ne r u nd F ra ue n, d ie b er ic ht et en , d as s s ie n ac h de r I nt er ve nt io n Ve rh üt un g an w en de te n. D er B ei tr ag s te llt fe st , d as s e s s ic h um e in en im Ve rg le ic h zu r A nw en du ng sr at e vo r d er In te rv en tio n (0 ,1 P ro ze nt fü r F ra ue n un d 0, 8 Pr oz en t f ür M än ne r) si gn ifi ka nt en A ns tie g ha nd el t. 7 G ill es pi e et a l., 2 00 9 8 Es h an de lt si ch u m d en A nt ei l d er F ra ue n in a kt ue lle n Se xu al be zi eh un ge n, d ie V er hü tu ng a nw en de te n. 9 H off m an e t a l., 2 00 8 10 K le in er S tic hp ro be nu m fa ng (n =2 27 ). 11 B ei d en 4 6 Pr oz en t h an de lt es si ch u m F ra ue n, d ie V er hü tu ng zu m Z ei tp un kt d er F ol ge be fr ag un g na ch e in em M on at a nw en de te n. Z um Z ei tp un kt d er F ol ge be fr ag un g na ch e in er W oc he w en de te n 52 P ro ze nt d er F ra ue n Ve rh üt un g an . D er N [G ru nd ge sa m th ei t] v on 2 00 b er üc ks ic ht ig t d ie je ni ge n Fr au en , d ie a us d er B eo ba ch tu ng fi el en o de r w äh re nd d er S tu di e ve rs ta rb en . 12 C ha bi ku li et a l., 2 00 9 13 D er B ei tr ag b er ic ht et v on e in em d ur ch sc hn it tli ch en m on at lic he n CY P vo n 38 ,2 n ac h de r I nt er ve nt io n, v er gl ic he n m it 32 ,3 v or d er In te rv en tio n – ei ne m si gn ifi ka nt en A ns tie g, d a di es e Er ge bn is se au f 4 4, 58 9 Pe rs on en b as ie re n, d ie F am ili en pl an un gs kl in ik en w äh re nd d es B er ic ht sz ei tr au m s a uf su ch te n. 14 N gu re e t a l., 2 00 9 15 H oh es R is ik o de r S tic hp ro be nv er ze rr un g; k ei ne V er bl in du ng , d ah er is t d as R is ik o de r V er ze rr un g au fg ru nd v on u nt er sc hi ed lic he n Be ha nd lu ng en u nk la r; ho he s R is ik o de r V er ze rr un g du rc h an de re Fa kt or en , d a di e Be su ch sf re qu en z un d di e An w en du ng sr at e vo n Ve rh üt un gs m it te ln b ei H IV -p os iti ve n Fr au en h öh er w ar en a ls b ei F ra ue n, d ie H IV -n eg at iv w ar en . 16 D ie se s C ha nc en ve rh äl tn is (O dd s R at io , O R) b er uh t a uf e in em V er gl ei ch d er A nt ei le v on B es uc he n, b ei d en en H IV -p os iti ve F ra ue n vo n de r V er w en du ng v on V er hü tu ng sm it te ln a uß er K on do m en be ric ht et en . F ür H IV -n eg at iv e Fr au en b et ru g da s O R= 2. 2 (9 5 Pr oz en t C I [ Ve rt ra ue ns in te rv al l]: 1 ,4 , 3 ,5 ). 17 R as ch e t a l., 2 00 6 18 B er ei ni gt es C ha nc en ve rh äl tn is (O R; E in flu ss v on A lte r, Fa m ili en st an d, fr üh er er G eb ur t u nd B er uf ) b as ie re nd a uf e in em V er gl ei ch m it de nj en ig en , d ie si ch w ei ge rt en , s ic h ei ne m H IV -T es t z u un te rz ie he n (9 7/ 29 9; 3 2, 9 Pr oz en t). 23 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de u- tu ng An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig - ke it W ei te re Fa kt or en Au fk lä ru ng ü be r d ie Ve rw en du ng v on Ve rh üt un gs m it te ln d ur ch Fr au en n ac h de r G eb ur t Ko nt ro lle Re la tiv (9 5 % CI ) Ab so lu t Ve rw en du ng v on V er hü tu ng sm it te ln n ac h de r G eb ur t ( er fa ss t m it te ls : B ef ra gu ng ) 14 ra nd o m is ie rt e St ud ie n er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t6 ke in e 17 0/ 29 9 (5 6, 9 % )7 19 /3 01 (6 ,3 % )8 – 63 w en ig er pr o 10 00 (v on 6 3 w en ig er b is 6 3 w en ig er ) ni ed rig be de u te nd 0 % – Ve rw en du ng v on V er hü tu ng sm it te ln n ac h de r G eb ur t 19 ra nd o m is ie rt e St ud ie n ke in e rn st ha ft es Ve rz er ru ng sr is ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 11 7/ 27 6 (4 2, 4 % )1 0 11 8/ 29 1 (4 0, 5 % ) – 40 5 w en ig er p ro 10 00 (v on 4 05 w en ig er b is 4 05 w en ig er ) ho ch be de u te nd 0 % – Ve rw en du ng v on V er hü tu ng sm it te ln n ac h de r G eb ur t ( er fa ss t m it te ls : B ef ra gu ng ) 11 1 ra nd o m is ie rt e St ud ie n er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – O R 1, 62 (1 ,0 6 bi s 2, 50 )1 3 – m od e ra t be de u te nd 0 % – Em pf eh lu ng 3 .6 In te gr at io n na ch d er G eb ur t Au to rin : P . W hy te D at um : 1 3. M är z 20 13 Fr ag e: S ol lte A ufk lä ru ng ü be r d ie n ac hg eb ur tli ch e Ve rw en du ng v on V er hü tu ng sm it te ln fü r F ra ue n na ch d er G eb ur t b er ei tg es te llt w er de n? 1, 2 Se tt in gs : U SA u nd v ie r w ei te re L än de r3 Bi bl io gr ap hi e: Lo pe z et a l., 2 01 2 24 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de u- tu ng An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig - ke it W ei te re Fa kt or en Au fk lä ru ng ü be r d ie Ve rw en du ng v on Ve rh üt un gs m it te ln d ur ch Fr au en n ac h de r G eb ur t Ko nt ro lle Re la tiv (9 5 % CI ) Ab so lu t Ve rw en du ng v on V er hü tu ng sm it te ln n ac h de r G eb ur t ( er fa ss t m it te ls : B ef ra gu ng ) 11 4 ra nd o m is ie rt e St ud ie n er ns th af t5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t1 6 ke in e 53 /6 2 (8 5, 5 % ) 40 /6 2 (6 4, 5 % ) RR 1 .3 3 (1 .0 7 bi s 1. 64 21 3 m eh r p ro 10 00 (v on 4 5 m eh r b is 4 13 m eh r) ni ed rig be de u te nd 0 % – Ve rw en du ng v on V er hü tu ng sm it te ln n ac h de r G eb ur t ( er fa ss t m it te ls : F ra ge bo ge n un d de s E in sa m m el ns v on P ill en pa ck un ge n) 11 7 ra nd o m is ie rt e St ud ie n er ns th af t1 5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t1 9 ke in e 4/ 16 (2 5 % )2 0 3/ 9 (3 3, 3 % )2 1 – 33 3 w en ig er p ro 10 00 (v on 3 33 w en ig er b is 3 33 w en ig er ) ni ed rig be de u te nd 0 % – 1 D ie Ü be rs ic ht sa rb ei t v on L op ez e t a l. (2 01 2) s te llt fe st , d as s v on d en z eh n be rü ck si ch tig te n St ud ie n nu r f ün f d ie V er w en du ng v on V er hü tu ng sm it te ln a ls E nd pu nk t h at te n. D a di e Ü be rs ic ht s- ar be it ke in e ag gr eg ie rt en A na ly se n de r v er fü gb ar en S tu di en li ef er t, w ird in d er v or lie ge nd en T ab el le je de S tu di e ei nz el n da rg es te llt . 2 Fü nf d er in d er Ü be rs ic ht sa rb ei t v on L op ez e t a l ( 20 12 ) b er üc ks ic ht ig te n St ud ie n fo ku ss ie rt en si ch a uf Ju ge nd lic he , e in e St ud ie fo ku ss ie rt e si ch a uf ju ng e Fr au en . D ie re st lic he n St ud ie n ha tt en ke in e Al te rs gr en ze n. V on d en S tu di en , d ie si ch a uf Ju ge nd lic he fo ku ss ie rt en , h at te n le di gl ic h zw ei d ie V er w en du ng v on V er hü tu ng sm it te ln a ls E nd pu nk t. 3 D ie Ü be rs ic ht sa rb ei t v on L op ez e t a l ( 20 12 ) u m fa ss te z eh n St ud ie n, w ov on s ec hs in d en U SA u nd je w ei ls e in e in A us tr al ie n, N ep al , P ak is ta n un d Sy rie n du rc hg ef üh rt w ur de n. 4 Sa ee d et a l., 2 00 8. B ei d er In te rv en tio n ha nd el te e s s ic h um V er hü tu ng sb er at un g na ch d er G eb ur t s ow ie d ie B er ei ts te llu ng e in es A ufk lä ru ng sm er kb la tt s. 5 Es w ur de n ke in e In fo rm at io ne n be zü gl ic h ve rd ec kt er Z ut ei lu ng [z u de n ve rg le ic he nd en G ru pp en ] g el ie fe rt . 6 D ie In te rv en tio n be st an d au s e in er 2 0- m in ut ig en in fo rm el le n Be ra tu ng u nd e in em e in se iti ge m F lu gb la tt zu m T he m a Ve rh üt un gs m et ho de n. D ie Ü be rs ic ht sa rb ei t v on L op ez e t a l ( 20 12 ) s tu ft e di e St ud ie a uf gr un d de r n ie dr ig en In te rv en tio ns qu al itä t a b. 7 12 9 w ei te re P er so ne n (4 3, 1 Pr oz en t) g ab en a n, d as s s ie in d en n äc hs te n se ch s M on at en d am it be gi nn en w ür de n, V er hü tu ng a nz uw en de n. 8 15 3 w ei te re P er so ne n (5 0, 8 Pr oz en t) g ab en a n, d as s s ie in d en n äc hs te n se ch s M on at en d am it be gi nn en w ür de n, V er hü tu ng a nz uw en de n. 9 Ba sh ou r e t a l., 2 00 8. D ie In te rv en tio n be st an d en tw ed er a us v ie r H au sb es uc he n na ch d er G eb ur t o de r a us e in em H au sb es uc h na ch d er G eb ur t. 10 In d ie se r S tu di e ga b es z w ei In te rv en tio ns gr up pe n. In d er e rs te n G ru pp e (m it vi er In te rv en tio ns be su ch en ) w en de te n 42 ,2 P ro ze nt d er T ei ln eh m er in ne n Ve rh üt un g an . I n de r z w ei te n G ru pp e (m it ei ne m In te rv en tio ns be su ch ) w en de te n 37 P ro ze nt (1 07 /2 89 ) d er T ei ln eh m er in ne n Ve rh üt un g an . 11 B ol am e t a l., 1 99 8. D ie In te rv en tio n um fa ss te e in en s tr uk tu rie rt en H au sh al ts fr ag eb og en (B as is be fr ag un g) s ow ie in di vi du el le g es un dh ei tli ch e Au fk lä ru ng zu m Z ei tp un kt d er G eb ur t u nd d re i M on at e da na ch . 12 D ie T ei ln eh m er in ne n un d G es un dh ei ts pä da go gi nn en /G es un dh ei ts pä da go ge n w ur de n ni ch t v er bl in de t. D ie R at e de re r, di e ni ch t a n ei ne r F ol ge be fr ag un g te iln ah m en , w ar h oc h – 25 P ro ze nt b ei de r F ol ge be fr ag un g na ch d re i M on at en u nd 2 7 Pr oz en t b ei d er F ol ge be fr ag un g na ch s ec hs M on at en . 13 In d ie se r S tu di e ga b es d re i E xp er im en ta lg ru pp en u nd e in e Ko nt ro llg ru pp e. D ie d re i E xp er im en ta lg ru pp en e rh ie lte n en tw ed er g es un dh ei tli ch e Au fk lä ru ng s of or t n ac h de r G eb ur t o de r d re i M on at e na ch d er G eb ur t ( G ru pp e A) , g es un dh ei tli ch e Au fk lä ru ng n ur zu m Z ei tp un kt d er G eb ur t ( G ru pp e B) o de r g es un dh ei tli ch e Au fk lä ru ng d re i M on at e na ch d er G eb ur t ( G ru pp e C) . D ie K on t- ro llg ru pp e (G ru pp e D ) e rh ie lt ke in e ge su nd he itl ic he A ufk lä ru ng . D er B ei tr ag v er gl ic h G ru pp en A u nd B e in er se it s m it G ru pp en C u nd D a nd er er se it s. D ie se r V er gl ei ch e rg ab d as h ie r a uf ge fü hr te O dd s R at io (O R; C ha nc en ve rh äl tn is) . D ie A nt ei le d er P at ie nt in ne n in je de r G ru pp e, d ie V er hü tu ng a nw en de te n, k ön ne n ni ch t i n G RA D E da rg es te llt w er de n, w ei l d er B ei tr ag d ie A nz ah l d er b ew er - te te n Pe rs on en in je de r G ru pp e ni ch t a ng ib t; er n en nt le di gl ic h di e G ru nd ge sa m th ei t ( N ) d er b ew er te te n Pe rs on en . D er B ei tr ag v er gl ic h zu de m G ru pp en A u nd C m it G ru pp en B u nd D . D ie se r 25 Ve rg le ic h er ga b ei n O R vo n 0, 86 (9 5 Pr oz en t C I [ Ve rt ra ue ns in te rv al l]: 0 ,5 8, 1 ,3 5) fü r d en V er gl ei ch d er V er w en du ng v on V er hü tu ng sm it te ln n ac h se ch s M on at en . E s w ur de n ke in e Ve rg le ic he vo rg en om m en z w is ch en d en E xp er im en ta lg ru pp en e in er se it s u nd d er K on tr ol lg ru pp e an de re rs ei ts . 14 Q ui nl iv an e t a l., 2 00 3. D ie In te rv en tio n be st an d au s f ün f s tr uk tu rie rt en H au sb es uc he n du rc h Kr an ke ns ch w es te r-H eb am m en n ac h de r G eb ur t. 15 U nk la re s R is ik o de r V er ze rr un g au fg ru nd v on u nt er sc hi ed lic he n Be ha nd lu ng en u nd fe hl en de r V er bl in du ng , d a ke in e In fo rm at io ne n üb er V er bl in du ng zu r V er fü gu ng g es te llt w ur de n. 16 K le in er N [G ru nd ge sa m th ei t] m it 13 9 au fg en om m en en u nd 1 24 b ew er te te n Pe rs on en . 17 G ill ia m e t a l., 2 00 4. D ie In te rv en tio n be st an d au s B er at un g, e in em V id eo ba nd ü be r o ra le V er hü tu ng sm it te l s ow ie s ch rif tli ch em M at er ia l. 18 U nk la re s R is ik o de r V er ze rr un g au fg ru nd v on u nt er sc hi ed lic he n Be ha nd lu ng en u nd fe hl en de r V er bl in du ng , d a ke in e In fo rm at io ne n üb er V er bl in du ng b er ei tg es te llt w ur de n. 19 K le in er n [S tic hp ro be nu m fa ng ] m it le di gl ic h 33 ra nd om is ie rt en P er so ne n; 5 2 Pr oz en t w ar en zu m Z ei tp un kt d er F ol ge be fr ag un g na ch e in em Ja hr a us ge sc hi ed en . 20 E s h an de lt si ch h ie r u m d ie A nt ei le v on F ra ue n, d ie n ac h ei ne m Ja hr im m er n oc h or al e Ve rh üt un gs m it te l v er w en de te n. W ei te re a ch t F ra ue n ha tt en a uf a nd er e Ve rh üt un gs m et ho de n um ge st el lt . D er B ei tr ag g ib t z w ar d ie G ru nd ge sa m th ei te n [N ] a n, d ie im B ei tr ag a ng eg eb en en P ro ze nt sä tz e be ru he n je do ch a uf d er G es am tz ah l d er T ei ln eh m er in ne n (n =2 5) , w äh re nd si e be i G RA D E na ch G ru pp en b er ec hn et w er de n. 21 E s h an de lt si ch h ie r u m d ie A nt ei le d er F ra ue n, d ie n ac h ei ne m Ja hr im m er n oc h or al e Ve rh üt un gs m it te l v er w en de te n. W ei te re d re i F ra ue n ha tt en a uf a nd er e Ve rh üt un gs m et ho de n um ge st el lt . D er B ei tr ag li ef er t z w ar d ie G ru nd ge sa m th ei te n [N ] a n, d ie in d em B ei tr ag a ng eg eb en en P ro ze nt sä tz e be ru he n je do ch a uf d er G es am tz ah l d er T ei ln eh m er in ne n (n =2 5) , w äh re nd si e be i G RA D E na ch G ru pp en b er ec hn et w er de n. 26 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be ra tu ng ü be r Fa m ili en pl an un g na ch S ch w an ge r- sc ha ft sa bb ru ch Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t w ie de rh ol te S ch w an ge rs ch af ts ab br üc he 12 Be ob ac h tu ng s st ud ie n er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t4 ke in e 7/ 27 6 (2 ,5 % ) 15 /2 81 (5 ,3 % ) – 53 w en ig er pr o 10 00 (v on 5 3 w en ig er b is 53 w en ig er )5 se hr ni ed rig be de ut en d 0 % – er ne ut e un ge pl an te S ch w an ge rs ch af t – m od er ne V er hü tu ng sm it te l 12 Be ob ac h tu ng s st ud ie n er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t4 ke in e 42 /2 76 (1 5, 2% ) 96 /2 81 (3 4, 2% ) O R 3, 38 (2 ,1 6 bi s 5, .2 9) 29 5 m eh r pr o 10 00 (v on 1 87 m eh r b is 3 91 m eh r) se hr ni ed rig be de ut en d 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 16 Be ob ac h tu ng s st ud ie n se hr er ns th af t ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t1 0 ke in e 37 8/ 45 6 (8 2, 9% )8 – – – se hr ni ed rig be de ut en d 0 % – Em pf eh lu ng 3 .7 In te gr at io n in D ie ns te fü r d ie V er so rg un g un d N ac hs or ge b ei m S ch w an ge rs ch af ts ab br uc h Au to rin : P . W hy te D at um : 2 5. M är z 20 13 Fr ag e: S ol lte B er at un g üb er F am ili en pl an un g na ch e in em S ch w an ge rs ch af ts ab br uc h be i F ra ue n in L än de rn m it ni ed rig em E in ko m m en b er ei tg es te llt w er de n? 1 Se tt in gs : L än de r m it ni ed rig em E in ko m m en Bi bl io gr ap hi e: T rip ne y et a l., 2 01 3 (W ei l d ie Ü be rs ic ht sa rb ei t v on T rip ne y et a l. w ed er zu sa m m en ge fa ss te E rg eb ni ss e no ch h in re ic he nd g en au e An ga be n lie fe rt , ko nn te n ke in e re le va nt en E rg eb ni ss e in d as G RA D E- Sy st em e in ge ge be n w er de n. D ah er w ur de n di e St ud ie n ei nz el n ve rw en de t.) 27 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be ra tu ng ü be r Fa m ili en pl an un g na ch S ch w an ge r- sc ha ft sa bb ru ch Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n 6 M on at e na ch d er In te rv en tio n (e rf as st m it te ls : B ef ra gu ng ) 19 Be ob ac h tu ng s st ud ie n ke in er ns th af te s Ve rz er ru ng s ris ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 12 1/ 12 3 (9 8, 4% ) 86 /1 23 (6 9, 9% ) RR 1 .4 1 (1 ,2 5 bi s 1, 58 ) 28 7 m eh r pr o 10 00 (v on 1 75 m eh r b is 4 06 m eh r) se hr ni ed rig be de ut en d 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 11 1, 12 Be ob ac h tu ng s st ud ie n se hr er ns th af t1 3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t1 0 ke in e – – – – m od e ra t be de ut en d 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 11 4 Be ob ac h tu ng s st ud ie n se hr er ns th af t1 5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 97 9/ 10 09 (9 7% )1 6 – O R 1, 23 (0 ,8 7 bi s 1. 72 )1 ,8 – se hr ni ed rig be de ut en d 0 % – w ie de rh ol te A bt re ib un ge n 0 % – – se hr ni ed rig be de ut en d Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : P rü fu ng v on V er fa hr en sl og bü ch er n (p ro ce du re lo gb oo ks ) 11 7 Be ob ac h tu ng s st ud ie n ke in er ns th af te s Ve rz er ru ng s ris ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 34 92 /4 46 2 (7 8, 3 % )1 8 – – – ni ed rig be de ut en d – 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 11 9 Be ob ac h tu ng s st ud ie n er ns th af t2 0 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 27 1/ 31 5 (8 6 % )2 1 – – – se hr ni ed rig be de ut en d – 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng v on Ä rz tin ne n/ Är zt en , „ Si ch tu ng “ de r K lie nt in ne nu nt er la ge n, B ef ra gu ng v on P at ie nt in ne n) 12 2 Be ob ac h tu ng s st ud ie n se hr er ns th af t2 3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – – – se hr ni ed rig be de ut en d – 0 % – 28 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be ra tu ng ü be r Fa m ili en pl an un g na ch S ch w an ge r- sc ha ft sa bb ru ch Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n 12 4 Be ob ac h tu ng s st ud ie n se hr er ns th af t2 5 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – – – se hr ni ed rig be de ut en d – 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 12 7, 28 Be ob ac h tu ng s st ud ie n ke in e – – – – se hr ni ed rig be de ut en d – 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n 12 9 Be ob ac h tu ng s st ud ie n se hr er ns th af t3 0 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 48 7/ 52 4 (9 2, 9 % )3 1 – – – se hr ni ed rig be de ut en d – 0 % – Ak ze pt an z un d/ od er A nw en du ng v on V er hü tu ng sm et ho de n (e rf as st m it te ls : B ef ra gu ng ) 13 2 Be ob ac h tu ng s st ud ie n se hr er ns th af t3 3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 49 5/ 52 1 (9 5 % )3 4 – – – se hr ni ed rig be de ut en d – 0 % – 1 D re i d er e rm it te lte n Be itr äg e lie fe rt en k ei ne re le va nt en In fo rm at io ne n un d ko nn te n da he r a uf gr un d ih re r E ig en sc ha ft en n ic ht in d as G RA D E- Sy st em e in ge ge be n w er de n. B ei M cL au rin e t al . ( 19 95 ) h an de lt es si ch u m e in en B ei tr ag , d er T he m en b ez üg lic h de r N ac hs or ge n ac h Sc hw an ge rs ch af ts ab br üc he n be ha nd el t u nd e in e Re ih e vo n Em pf eh lu ng en a uff üh rt , d ie v on e in er Ar be it sg ru pp e fü r p riv at e un d öff en tli ch e D ie ns te im B er ei ch S ch w an ge rs ch af ts ab br uc h au sg es pr oc he n w ur de n. In d ie se m B ei tr ag w er de n w ed er In te rv en tio ne n no ch S tu di en te iln eh m er in - ne n b es ch rie be n. E s w er de n au ch k ei ne E rg eb ni ss e ge na nn t. D er B ei tr ag v on M ai la e t a l. (1 99 7) b es ch re ib t e in en D ie ns t f ür N ac hs or ge n ac h Sc hw an ge rs ch af ts ab br üc he n, d er 1 99 5 in N ep al ei ng er ic ht et w ur de . E s w ird b er ic ht et , d as s d ie A kz ep ta nz d er F am ili en pl an un g ho ch g ew es en s ei (7 0 Pr oz en t). E s w er de n ke in e An ga be n üb er d ie A nz ah l d er b et ei lig te n Pa tie nt in ne n ge m ac ht . D er B ei tr ag e rk lä rt zu de m , d as s F am ili en pl an un g in d er R eg el d ie B er at un g vo n Eh em än ne rn u nd E he fr au en u m fa ss te . E r s te llt je do ch a uc h fe st , d as s d ie B er at un g al le n Pa tie nt in ne n be re it- ge st el lt w ur de . D er B ei tr ag v on N ov em be r 2 01 2 üb er F am ili en pl an un g na ch e in em S ch w an ge rs ch af ts ab br uc h be sc hr ei bt A sp ek te e in er R ei he v on P ro gr am m en u nd fa ss t d en A nt ei l d er Fr au en zu sa m m en , d ie V er hü tu ng sm it te l v or u nd n ac h de r „ St är ku ng “ d er F am ili en pl an un gs di en st e in v er sc hi ed en en L än de rn e rh ie lte n. D ie se E rg eb ni ss e ko nn te n ni ch t i n da s G RA D E- Sy st em ei ng eg eb en w er de n. 2 Jo hn so n et a l., 2 00 2 3 D ie S tu di e um fa ss te le di gl ic h Fr au en , d ie ih re n äc hs te S ch w an ge rs ch af t f ür m in de st en s z w ei Ja hr e au fs ch ie be n w ol lte n. S om it lie gt d ie A nn ah m e ei ne s p ot en zi el l e rh öh te n In te re ss es a n od er de r V er w en du ng v on F am ili en pl an un g na he . 4 Fü r d ie m ei st en E nd pu nk te la g di e An za hl d er E re ig ni ss e un te r 3 00 (d em b ei G RA D E al s F au st re ge l g el te nd en S ch w el le nw er t). 5 G RA D E- Be re ch nu ng ; d er B ei tr ag li ef er t k ei ne A ng ab en zu re la tiv en o de r a bs ol ut en E ff ek te n. 6 M in is tr y of H ea lth v on B ur ki na F as o, 1 98 8 7 Es g ib t k ei ne H in w ei se , d as s d ie se lb en P at ie nt in ne n vo r u nd n ac h de r I nt er ve nt io n be fr ag t w ur de n. D er B ei tr ag b er ic ht et , d as s 3 00 P at ie nt in ne n vo r d er In te rv en tio n be fr ag t w ur de n un d 45 6 da na ch . 8 Es g ab k ei ne K on tr ol lg ru pp e be i d ie se r S tu di e, d ah er g ib t e s k ei ne E rg eb ni ss e. D er B ei tr ag li ef er t k ei ne A ng ab en zu re la tiv en o de r a bs ol ut en E ff ek te n fü r d ie U nt er sc hi ed e [z w is ch en d er R at e] d er An w en du ng v on V er hü tu ng v or u nd n ac h de r I nt er ve nt io n. E r g ib t l ed ig lic h de n An te il de r T ei ln eh m er in ne n an , d ie e in e Fa m ili en pl an un gs m et ho de a nw en de te n. 29 9 Fe rr ei ra e t a l., 2 01 1 10 D er G es am t- N [G es am t- G ru nd ge sa m th ei t] li eg t u nt er 3 00 . 11 D ia z et a l. 12 E s k on nt en k ei ne E rg eb ni ss e au s d ie se r S tu di e in d as G RA D E- Sy st em e in ge ge be n w er de n. D er B ei tr ag g ib t l ed ig lic h di e du rc hs ch ni tt lic he A nz ah l d er F ra ue n an , d ie a n dr ei K ra nk en hä us er n w eg en K om pl ik at io ne n na ch e in em S ch w an ge rs ch af ts ab br uc h be ha nd el t w ur de n. E r g ib t d an n di e Pr oz en ts ät ze d er F ra ue n an , d ie V er hü tu ng zu d re i v er sc hi ed en en Z ei tp un kt en in A ns pr uc h ge no m m en h ab en (n ac h Ve rh üt un gs ar t; di e Pr oz en ts ät ze re ic he n vo n 4, 3 Pr oz en t b is 3 9, 0 Pr oz en t). G RA D E er fo rd er t d ie E in ga be v on Z äh le rn u nd N en ne rn ; P ro ze nt sä tz e al le in k ön ne n ni ch t ei ng eg eb en w er de n. D ie N [G ru nd ge sa m th ei te n] in d ie se r S tu di e ko nn te n ni ch t a nh an d de r i m B ei tr ag g el ie fe rt en In fo rm at io ne n er m it te lt w er de n. 13 E s h an de lt si ch u m e in e Be ob ac ht un gs st ud ie b ez üg lic h ei ne s P ro gr am m s, da s a n dr ei K ra nk en hä us er n ei ng er ic ht et w ur de . E s s ch ei nt e in e ge w is se In ko ns is te nz zu g eb en z w is ch en d en e ig en t- lic he n Pr og ra m m en a n je de m K ra nk en ha us . D ie A ut or en n en ne n w ie de rh ol t u nt er sc hi ed lic he N iv ea us d er „ Ak ze pt an z“ in d en v er sc hi ed en en B er ei ch en . 14 M ah om ed e t a l., 1 99 7 15 A ng es ic ht s d er T at sa ch e, d as s d ie G ru nd ge sa m th ei t [ N ] n ic ht k on si st en t z u se in s ch ei nt , i st h ie r e in V er ze rr un gs po te nz ia l v or ha nd en . N ac h de r I nt er ve nt io n w ur de n m eh r P at ie nt in ne n au fg ef üh rt a ls d av or . D ar üb er h in au s g ab e s k ei ne K on tr ol lg ru pp e. 16 E s g ab k ei ne K on tr ol lg ru pp e. D ar üb er h in au s w ur de n ke in e re la tiv en o de r a bs ol ut en E ff ek te im H in bl ic k au f U nt er sc hi ed e vo r u nd n ac h de r I nt er ve nt io n ge na nn t. 17 O ts ea e t a l., 2 01 1 18 E s g ab k ei ne V er gl ei ch sg ru pp e un d es w er de n ke in e re la tiv en o de r a bs ol ut en U nt er sc hi ed e im H in bl ic k au f U nt er sc hi ed e vo r u nd n ac h de m P ro gr am m g en an nt . 19 R as ch e t a l., 2 00 4 20 D ie S tu di e be rü ck si ch tig t n ic ht d ie P at ie nt in ne n, d ie zu m Z ei tp un kt d er F ol ge be fr ag un g be re it s a us ge sc hi ed en w ar en ; d er Z ei tp un kt d er F ol ge be fr ag un g re ic ht e vo n ei ne m M on at b is zu s ec hs M on at en n ac h de r B as is be fr ag un g. 21 E s g ab k ei ne K on tr ol lg ru pp e; d ie S tu di e lie fe rt k ei ne E in sc hä tz un g de r r el at iv en o de r a bs ol ut en E ff ek te ; e s w er de n le di gl ic h di e Pr oz en ts ät ze a ng eg eb en . 22 R og o et a l., 1 99 8 23 D er B ei tr ag g ib t k ei ne n H in w ei s a uf d ie A nz ah l d er Ä rz tin ne n un d Är zt e, d ie ta ts äc hl ic h te iln ah m en . D as e in zi ge E rg eb ni s b ez üg lic h de r A kz ep ta nz o de r d er A nw en du ng v on V er hü tu ng , d as be ric ht et w ird , l au te t, da ss z w is ch en 1 2, 5 Pr oz en t u nd 1 00 P ro ze nt d er K lie nt in ne n un d Kl ie nt en d ie E in ric ht un g m it ei ne r F am ili en pl an un gs m et ho de v er lie ße n. E s w er de n w ed er A ng ab en ü be r di e M et ho de na rt g em ac ht n oc h da rü be r, ob si e ta ts äc hl ic h an ge w en de t w ur de . 24 S ol o et a l., 1 99 9 25 D ie S tu di e se tz te d re i v er sc hi ed en e Fa m ili en pl an un gs m od el le e in . D as h ei ßt , d as s d ie A nb ie te r d er F am ili en pl an un gs di en st e un d di e Be re it st el lu ng ss ta nd or te v ar iie rt en . D as e in zi ge E rg eb ni s be zü gl ic h de r V er w en du ng v on V er hü tu ng sm it te ln w ar d er A nt ei l d er P at ie nt in ne n, d ie d as K ra nk en ha us m it ei ne r V er hü tu ng sm et ho de v er lie ße n. B ei M od el l 1 (F am ili en pl an un gs di en st e au f de r g yn äk ol og is ch en S ta tio n vo m [S ta tio ns -]P er so na l b er ei tg es te llt ) w ur de d ie se r A nt ei l m it 82 P ro ze nt a ng eg eb en ; b ei M od el l 2 (F am ili en pl an un gs di en st e au f d er g yn äk ol og is ch en S ta tio n vo n Pe rs on al b er ei tg es te llt , d as fü r d ie G es un dh ei t v on M üt te rn u nd K in de rn zu st än di g w ar ) b et ru g de r A nt ei l 6 3 Pr oz en t; be i M od el l 3 (F am ili en pl an un gs di en st e in e in er K lin ik fü r M üt te r b er ei tg e- st el lt un d Fa m ili en pl an un g vo m P er so na l b er ei tg es te llt ) w ur de d er A nt ei l m it 75 P ro ze nt a ng eg eb en . D ie G ru nd ge sa m th ei t [ N ] d er P at ie nt in ne n be i j ed em M od el l, di e en tw ed er d er In te rv en tio n au sg es et zt w ur de n od er E rg eb ni ss e lie fe rt en , w ur de n ic ht a ng eg eb en . D er B eg in n de r P ro gr am m e va rii er te e be nf al ls n ac h M od el l u nd S ta nd or t. 26 D ie A nz ah l d er P at ie nt in ne n, d ie d ie v er sc hi ed en en M od el le a nw en de te n, is t n ic ht b ek an nt 27 T ha pa e t a l., 2 00 4 28 D ie se S tu di e be w er te te D ie ns te fü r m an ue lle A bs au gu ng (M VA ) i n N ep al u nd v er gl ic h si e m it Ab tr ei bu ng sd ie ns te n, d ie im H au pt op er at io ns sa al a ng eb ot en w ur de n. A n si ch b ef as st si ch d ie St ud ie n ic ht d ire kt m it Fa m ili en pl an un gs be ra tu ng n ac h ei ne m S ch w an ge rs ch af ts ab br uc h, w en ng le ic h Pa tie nt in ne n et w as B er at un g er hi el te n. D er A nt ei l d er M VA -P at ie nt in ne n, d ie s ec hs W o- ch en n ac h de m S ch w an ge rs ch af ts ab br uc h Ve rh üt un gs m it te l v er w en de te n, w ird m it 53 ,5 P ro ze nt a ng eg eb en . D er B ei tr ag w ei st d ar au f h in , d as s d ie se Z ah l a uf 8 5 Te iln eh m er in ne n ba si er te . E r be ric ht et , d as s 5 29 F äl le in d er M VA -E in he it be ha nd el t w ur de n un d da ss d ie S tic hp ro be (n =8 5) le di gl ic h 16 P ro ze nt d er P at ie nt in ne n re pr äs en tie rt e. D er B ei tr ag b er ic ht et fe rn er , d as s 8 3, 6 Pr o- ze nt d er M VA -G ru pp e zu r F ol ge -U nt er su ch un g na ch s ec hs W oc he n er sc hi en en . D ie D is kr ep an z be i d en G ru nd ge sa m th ei te n [N ] i st d ah er u nk la r. 29 R as ch e t a l., 2 00 5 30 E s h at d en A ns ch ei n, d as s g er in gf üg ig u nt er sc hi ed lic he B er at un gs pr og ra m m e an d en v er sc hi ed en en K ra nk en hä us er n an ge bo te n w ur de n. E in V er gl ei ch m it de r A nw en du ng v on V er hü tu ng du rc h di e Te iln eh m er in ne n vo r d er B er at un g fa nd n ic ht s ta tt . E s i st d ah er s ch w ie rig , d ie E ff ek te d es P ro gr am m s z u be ur te ile n. 31 D ie se r P ro ze nt sa tz b ez ie ht si ch a uf F ra ue n in s tä dt is ch en G eb ie te n in T an sa ni a. D ie E rg eb ni ss e fü r l än dl ic he G eb ie te in T an sa ni a la ut en : E in e Ve rh üt un gs m et ho de w ur de 1 72 d er 2 42 F ra ue n (7 1 Pr oz en t) zu r V er fü gu ng g es te llt . 32 R as ch e t a l., 2 00 7 33 D as V er ze rr un gs ris ik o is t h oc h, d a es si ch u m e in e Be ob ac ht un gs st ud ie h an de lt . F er ne r w ur de k ei n Ve rg le ic h m it de r A nw en du ng v on V er hü tu ng v or d er B er at un g vo rg en om m en . 34 9 5 Pr oz en t d er P at ie nt in ne n ve rli eß en d ie K ra nk en ha us st at io n m it ei ne r V er hü tu ng sm et ho de . D as K on do m fü r d ie F ra u w ur de v on 2 01 d er 5 21 F ra ue n (3 9 Pr oz en t) a ng en om m en u nd v on 1 58 de r 5 21 F ra ue n (3 0 Pr oz en t) b en ut zt . 30 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be re it st el - lu ng m ob ile r au fs uc he nd er D ie ns te Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ei ns te llu ng d er N ut zu ng e in es In tr au te rin pe ss ar s ( IU D ) 11 Be ob ac h tu ng s st ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –3 – – – se hr ni ed rig be de ut en d 0 % – 1 Az m at e t a l., 2 01 3 2 Be fr ag un ge n w ar en re tr os pe kt iv er A rt . D ah er k an n es zu e in er V er ze rr un g au fg ru nd e in es u ng en au en E rin ne ru ng sv er m ög en s k om m en ; d ar üb er h in au s w ur de n di e D at en v on d en B ef ra gt en se lb st b er ic ht et . 3 19 ,4 P ro ze nt d er F ra ue n st el lte n di e N ut zu ng d er IU D n ac h 10 M on at en e in (9 5 Pr oz en t C I [ Ve rt ra ue ns in te rv al l]: 1 6, 3, 2 2, 5) . Em pf eh lu ng 3 .8 M ob ile D ie ns te Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte n m ob ile a uf su ch en de D ie ns te b ei F ra ue n ei ng es et zt w er de n? Se tt in gs : P ak is ta n Bi bl io gr ap hi e: 31 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be re it st el - lu ng m ob ile r au fs uc he nd er D ie ns te Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ei ns te llu ng d er N ut zu ng e in es In tr au te rin pe ss ar s ( IU D ) 11 Be ob ac h tu ng s st ud ie n ke in er ns th af te s Ve rz er ru ng s ris ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e –2 – – – ni ed rig be de ut en d 0 % – 1 Ev a un d N go (2 01 0) 2 D er P ro ze nt sa tz d er F ra ue n, d ie d ie N ut zu ng n ac h ac ht M on at en e in st el lte n: b ei Im pl an ta te n: 5 ,7 P ro ze nt in Ä th io pi en u nd 6 ,2 P ro ze nt in S ie rr a Le on e; b ei IU D : 1 6, 9 Pr oz en t i n Si er ra L eo ne , 20 ,9 P ro ze nt in M ya nm ar , 1 8, 9 Pr oz en t i n Pa ki st an u nd 2 ,3 P ro ze nt in V ie tn am Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte e in m ob ile r a uf su ch en de r D ie ns t b ei F ra ue n ei ng es et zt w er de n, d en en In tr au te rin pe ss ar e un d Im pl an ta te e in ge se tz t w er de n? Se tt in gs : Ä th io pi en , M ya nm ar , P ak is ta n, S ie rr a Le on e, V ie tn am Bi bl io gr ap hi e: 32 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en M ob ile r au fs uc he nd er D ie ns t f ür IU D Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ei ns te llu ng d er N ut zu ng e in es In tr au te rin pe ss ar s ( IU D ) 11 Be ob ac h tu ng s st ud ie n2 ke in er ns th af te s Ve rz er ru ng s ris ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e 15 1/ 13 48 (1 1, 2 % ) – – – ni ed rig be de ut en d 0 % – 1 N go u nd P er ni to (2 01 0) 2 Re tr os pe kt iv e D at en an al ys e. Ra te n de r E in st el lu ng d er N ut zu ng v on IU D n ac h ei ne m Ja hr b ei N ut ze rin ne n vo n m ob ile n Kl in ik en Au to rin : P . W hy te D at um : 1 0. A pr il 20 13 Fr ag e: S ol lte e in m ob ile r a uf su ch en de r D ie ns t f ür In tr au te rin pe ss ar e (IU D ) b ei F ra ue n ei ng es et zt w er de n? Se tt in gs : P hi lip pi ne n Bi bl io gr ap hi e: 33 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en G em ei nd en ah er An sa tz Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t An w en du ng e in er m od er ne n re ve rs ib le n Ve rh üt un gs m et ho de (e rf as st m it te ls : B ef ra gu ng ) 11 Be ob ac h tu ng s st ud ie n2 ke in er ns th af te s Ve rz er ru ng s ris ik o er ns th af t3 ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it3 ke in e – – O R 1, 74 (1 ,1 1 bi s 2 ,7 1) 4 – se hr ni ed rig 0 % – 1 Su lta n et a l., 2 00 2 2 Re tr os pe kt iv e An al ys e de r U m fr ag ed at en . 3 Re tr os pe kt iv e D at en an al ys e; d ah er b es ch rä nk te M ög lic hk ei t, ei ne V er bi nd un g zw is ch en K au sa lfa kt or en h er zu st el le n. 4 D as b er ei ni gt e O dd s R at io (O R, C ha nc en ve rh äl tn is) z ei gt , d as s b ei F ra ue n, d ie h öc hs te ns 5 k m v on z w ei G em ei nd ea rb ei te rin ne n be zi eh un gs w ei se -a rb ei te rn e nt fe rn t l eb te n, d ie W ah rs ch ei nl ic h- ke it de r A nw en du ng m od er ne r V er hü tu ng sm et ho de n si gn ifi ka nt h öh er w ar a ls b ei F ra ue n, d ie k ei ne n Zu ga ng zu G em ei nd ea rb ei te rin ne n be zi eh un gs w ei se -a rb ei te rn h at te n. Au to rin : P . W hy te D at um : 2 0. M är z 20 13 Fr ag e: S ol lte e in g em ei nd en ah er A ns at z be i e in er lä nd lic he n Be vö lk er un g an ge w en de t w er de n? Se tt in gs : P ak is ta n Bi bl io gr ap hi e: 34 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Se lb st be ur - te ilu ng u nd / od er P ee r Re vi ew v on An bi et er n Ke in e Se lb st - be ur te ilu ng od er P ee r Re vi ew Re la tiv (9 5 % C I) Ab so lu t Zu fr ie de nh ei ts be w er tu ng d ur ch d ie K lie nt in ne n/ Kl ie nt en 11 Be ob ac h tu ng s st ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e –3 – – – se hr ni ed rig be de ut en d 0 % – 1 Ki m e t a l., 2 00 0 2 D ie A ut or en s te lle n fe st , d as s Q ua lit ät sv er be ss er un ge n ni ch t m it En dp un kt ve rh al te n w ie d er fo rt ge se tz te n Ve rw en du ng v on V er hü tu ng sm it te ln in B ez ie hu ng g es et zt w er de n kö nn en . 3 D er B ei tr ag b er ic ht et , d as s e s i n de r S el bs tb eu rt ei lu ng s- In te rv en tio ns gr up pe si gn ifi ka nt e An st ie ge d er Z uf rie de nh ei t d er K lie nt in ne n un d Kl ie nt en m it de r A uf m er ks am ke it de s A nb ie te rs (v on 4 ,3 a uf 4 ,4 ) s ow ie m it de r D ec ku ng v on B ed ar fe n (v on 4 ,1 a uf 4 .,3 ) g ab , g em es se n an ha nd e in er n ic ht va lid ie rt en S ka la . D er B ei tr ag li ef er t j ed oc h ke in e st at is tis ch en E rg eb ni ss e, d ie b el eg en , da ss e s t at sä ch lic h „s ig ni fik an te A ns tie ge “ g eg eb en h at . Em pf eh lu ng 3 .9 A bs ch aff un g de s E rf or de rn is se s d er Z us tim m un g D rit te r D ie se E m pf eh lu ng b er uh t a uf M en sc he nr ec ht sn or m en (A nh an g E) . D ah er w ur de k ei ne g es un dh ei tli ch e Ev id en z ge su ch t. Em pf eh lu ng 3 .1 0 Ab sc ha ff un g de s E rf or de rn is se s d er B en ac hr ic ht ig un g de r E lte rn D ie se E m pf eh lu ng b er uh t a uf M en sc he nr ec ht sn or m en (A nh an g E) . D ah er w ur de k ei ne g es un dh ei tli ch e Ev id en z ge su ch t. 4. A kz ep ta nz Em pf eh lu ng 4 .1 B er at un gs in te rv en tio ne n Au to rin : P . W hy te D at um : 1 1. A pr il 2 01 3 Fr ag e: S ol lte (n ) S el bs tb eu rt ei lu ng u nd /o de r P ee r R ev ie w v s. ke in e Se lb st be ur te ilu ng o de r P ee r R ev ie w b ei D ie ns ta nb ie te rn v er w en de t w er de n? Se tt in gs : I nd on es ie n Bi bl io gr ap hi e: 35 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Au sg ew og en e Be ra tu ng s- st ra te gi e Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ra te n de r A nw en du ng v on F am ili en pl an un g 11 Be ob ac h tu ng s st ud ie n ke in er ns th af te s Ve rz er ru ng s ris ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e –2 – – – ni ed rig 0 % – 1 Le on e t a l., 2 00 3 2 D er B ei tr ag li ef er t l ed ig lic h Sc ha ub ild er m it An w en du ng sr at en ; W er te k on nt en n ic ht e rm it te lt w er de n. D er B ei tr ag s te llt fe st , d as s d ie R at en d er A nw en du ng v on F am ili en pl an un g ni ch t ve re in ba r m it de r H yp ot he se d er S tu di e w ar en , w on ac h di e fo rt ge se tz te A nw en du ng v on F am ili en pl an un g na ch V er be ss er un ge n de r V er so rg un gs qu al itä t a ns te ig en w ür de . S ta tt de ss en s ch ie n di e An w en du ng v on F am ili en pl an un g zu rü ck zu ge he n. Au to rin : P . W hy te D at um : 1 1. A pr il 20 13 Fr ag e: S ol lte e in e au sg ew og en e Be ra tu ng ss tr at eg ie b ei Ä rz tin ne n un d Är zt en u nd S oz ia la rb ei te rin ne n un d So zi al ar be ite rn a ng ew en de t w er de n? Se tt in gs : G ua te m al a Bi bl io gr ap hi e: 36 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en M aß na hm en z ur Ve rb es se ru ng d er Kl ie nt in ne n- An bi et er In te ra kt io ne n Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Zu fr ie de nh ei t m it de n D ie ns te n de r K lin ik 11 Be ob ac h tu ng s st ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e –3 – – – se hr ni ed rig 0 % – 1 N aw ar e t a l., 2 00 4 2 Ei n Ri si ko d er V er ze rr un g au fg ru nd fe hl en de r E nd pu nk td at en (a tt rit io n bi as ) b es te ht , d a le di gl ic h kn ap p di e H äl ft e de r F ra ue n fü r F ol ge be su ch e in d ie K lin ik zu rü ck ge ke hr t s in d. 3 D er B ei tr ag b er ic ht et , d as s b ei d em F ol ge be su ch n ac h si eb en M on at en 7 2 Pr oz en t d er F ra ue n in d er In te rv en tio ns gr up pe si ch m it de n D ie ns te n de r K lin ik zu fr ie de n äu ße rt en , v er gl ic he n m it 55 P ro ze nt d er F ra ue n in d er K on tr ol lg ru pp e. B ei d em F ol ge be su ch n ac h 13 M on at en ä uß er te n si ch 8 1 Pr oz en t d er F ra ue n in d er In te rv en tio ns gr up pe u nd 6 1 Pr oz en t d er F ra ue n in d er Ko nt ro llg ru pp e zu fr ie de n. Au to rin : P . W hy te D at um : 1 1. A pr il 20 13 Fr ag e: S ol lte (n ) M aß na hm en zu r V er be ss er un g vo n Kl ie nt in ne n- An bi et er -In te ra kt io ne n vs . k ei ne In te rv en tio n be i F ra ue n ei ng es et zt w er de n? Se tt in gs : Ä gy pt en Bi bl io gr ap hi e: 37 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua li- tä t Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Sc hu lu ng s- pr og ra m m z ur Ve rb es se ru ng de r K om m un ik a- tio ns fä hi gk ei t Ke in Sc hu lu ng s- pr og ra m m Re la tiv (9 5 % C I) Ab so lu t Kl ie nt in ne nz uf rie de nh ei t 12 ra nd o m is ie rt e st ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t4 ke in e 30 /4 7 (6 3, 8% ) 16 /4 7 (3 4% ) – 34 0 w en ig er pr o 10 00 (v on 34 0 w en i ge r b is 3 40 w en ig er ) ni ed rig be de ut en d 0 % – 1 Zu sä tz lic he s S ch ul un gs pr og ra m m zu r V er be ss er un g de r K om m un ik at io ns fä hi gk ei t n eb en d er re gu lä re n Au sb ild un g. 2 Ya zd i e t a l., 2 00 8 3 D ie A ut or en s te lle n fe st , d as s d ie B eu rt ei lu ng d es E nd pu nk ts b ez üg lic h Kl ie nt in ne nz uf rie de nh ei t e in ge sc hr än kt s ei , d a da s S pe kt ru m d er e in ge se tz te n Fr ag eb ög en b eg re nz t w ar . 4 D ie A nz ah l d er K lie nt in ne n (n =4 7) in d er In te rv en tio ns - u nd d er K on tr ol lg ru pp e w ar g er in g. Em pf eh lu ng 4 .2 N ac hs or ge nd e Be ra tu ng D ie se E m pf eh lu ng b er uh t a uf M en sc he nr ec ht sn or m en (A nh an g D ). D ah er w ur de n ic ht n ac h ge su nd he itl ic he r E vi de nz g es uc ht . Au to rin : P . W hy te D at um : 1 1. A pr il 20 13 Fr ag e: S ol lte e in S ch ul un gs pr og ra m m zu r V er be ss er un g de r K om m un ik at io ns fä hi gk ei t v s. ke in S ch ul un gs pr og ra m m b ei G es un dh ei ts di en st le is te rn e in ge se tz t w er de n? 1 Se tt in gs : I ra n Bi bl io gr ap hi e: 38 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en N at io na le In iti at iv e fü r ju ge nd fr eu nd - lic he K lin ik en Ko nt ro ll- kl in ik en Re la tiv (9 5 % C I) Ab so lu t G es am tw er t d er K lin ik (e rf as st m it te ls : B ef ra gu ng ) 12 Be ob ac h tu ng s st ud ie n er ns th af t3 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e –4 0 % – – se hr ni ed rig be de ut en d 1 D ie N at io na le In iti at iv e fü r j ug en df re un dl ic he K lin ik en (N AF CI ) b er uh te a uf e in em Q ua lit ät sd re ie ck m it de n Ec kp un kt en „Q ua lit ät d efi ni er en “, „Q ua lit ät v er be ss er n“ u nd „Q ua lit ät m es se n“ . „Q ua lit ät “ w ur de a ls S ta nd ar ds v on ju ge nd fr eu nd lic he n D ie ns te n de fin ie rt ; d ie S ta nd ar ds u nd K rit er ie n w ur de n au f d er B as is v on e ta bl ie rt en C ha ra kt er is tik a un d Ei ge ns ch af te n vo n ju ge nd - fr eu nd lic he n D ie ns te n en tw ic ke lt . D ie Q ua lit ät sm es su ng e rf ol gt e m ith ilf e ei ne s S el bs tb eu rt ei lu ng sp ro ze ss es s ow ie e xt er ne r B eu rt ei lu ng . D ie Q ua lit ät sv er be ss er un gs m aß na hm e um fa ss te d ie Bi ld un g vo n Te am s i n je de r K lin ik s ow ie e xt er n ge sc hu lte B eg le ite rin ne n un d Be gl ei te r, di e di e Te am s u nt er st üt zt en . 2 D ic ks on e t a l., 2 00 7 3 D er B ei tr ag s te llt e da s R is ik o de r S tic hp ro be nv er ze rr un g so w ie u nz ur ei ch en de s ta tis tis ch e Au ss ag ek ra ft a uf gr un d de r k le in en A nz ah l v on K lin ik en (1 1 Ex pe rim en ta lk lin ik en , 1 1 Ko nt ro llk lin ik en ) fe st . E r s te llt e au ße rd em e in en M an ge l a n ju ge nd lic he n Kl ie nt in ne n un d Kl ie nt en a n m an ch en K lin ik en fe st (S im ul at io ne n w ur de n du rc hg ef üh rt a ns ta tt e ch te K lie nt in -A nb ie te r I nt er ak tio ne n) . 4 D er B ei tr ag b er ic ht et , d as s d er D ur ch sc hn it ts w er t v on a lle n Ex pe rim en ta lk lin ik en 7 9, 9 Pr oz en t b et ru g, v er gl ic he n m it 60 ,9 P ro ze nt (p =0 ,0 05 ) b ei d en K on tr ol lk lin ik en . 5. Q ua lit ät Em pf eh lu ng 5 .1 Q ua lit ät ss ic he ru ng sp ro ze ss e Au to rin : P . W hy te D at um : 1 1. A pr il 20 13 Fr ag e: S ol lte e in e na tio na le In iti at iv e fü r j ug en df re un dl ic he K lin ik en v s. Ko nt ro llk lin ik en b ei Ju ge nd lic he n ei ng es et zt w er de n? 1 Se tt in gs : S üd af rik a Bi bl io gr ap hi e: 39 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua li- tä t Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Ve rb es se ru ng vo n Kl ie nt in ne n- An bi et er - In te ra kt io ne n Ke in e In te r- ve nt io n Re la tiv (9 5 % C I) Ab so lu t Kl ie nt in ne nz uf rie de nh ei t 11 Be ob ac h tu ng s st ud ie n er ns th af t2 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e –3 – – – se hr ni ed rig be de ut en d 0 % – 1 N aw ar e t a l., 2 00 4 2 Es b es te ht e in V er ze rr un gs ris ik o au fg ru nd fe hl en de r E nd pu nk td at en , d a le di gl ic h kn ap p di e H äl ft e de r F ra ue n fü r F ol ge be su ch e in d ie K lin ik en zu rü ck ke hr te n. 3 D er B ei tr ag b er ic ht et , d as s 7 2 Pr oz en t d er F ra ue n in d er In te rv en tio ns gr up pe si ch b ei m F ol ge be su ch n ac h si eb en M on at en m it de n Kl in ik di en st en zu fr ie de n äu ße rt en , v er gl ic he n m it 55 P ro ze nt de r F ra ue n in d er K on tr ol lg ru pp e. B ei m F ol ge be su ch n ac h 13 M on at en ä uß er te n si ch 8 1 Pr oz en t d er F ra ue n in d er In te rv en tio ns gr up pe u nd 6 1 Pr oz en t d er F ra ue n in d er K on tr ol lg ru pp e zu fr ie de n. Em pf eh lu ng 5 .2 U m ga ng m it La ng ze it ve rh üt un gs m it te ln D ie se E m pf eh lu ng b er uh t a uf M en sc he nr ec ht sn or m en (A nh an g E) . D ah er w ur de k ei ne g es un dh ei tli ch e Ev id en z ge su ch t. Em pf eh lu ng 5 .3 S ch ul un g vo n An bi et er n D ie se E m pf eh lu ng b er uh t a uf M en sc he nr ec ht sn or m en (A nh an g E) . D ah er w ur de k ei ne g es un dh ei tli ch e Ev id en z ge su ch t. Au to rin : P . W hy te D at um : 1 1. A pr il 20 13 Fr ag e: S ol lte n M aß na hm en zu r V er be ss er un g vo n Kl ie nt in ne n- An bi et er -In te ra kt io ne n vs . k ei ne In te rv en tio n be i F ra ue n er gr iff en w er de n? Se tt in gs : Ä gy pt en Bi bl io gr ap hi e: 40 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Pr og ra m m zu r F ör de ru ng ör tli ch er In iti at iv en Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t An st ie g de r V er w en du ng v on V er hü tu ng sm it te ln 2 ( er fa ss t m it te ls : B ef ra gu ng ) 13 Be ob ac h tu ng s st ud ie n se hr er ns th af t4 ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e – – – – se hr ni ed rig be de ut en d 0 % – 1 D ie S tu di e be w er te te P ro gr am m e zu r F ör de ru ng ö rt lic he r I ni tia tiv en in d re i R eg io ne n in In di en : d en E le nd sv ie rt el n vo n Ko lk at a, P un ja b un d H im ac ha l P ra de sh u nd U tt ar an ch al . 2 D ie A nt ei le d er T ei ln eh m er in ne n, d ie V er hü tu ng zu B eg in n de r I nt er ve nt io n so w ie a m E nd e de s P ro gr am m s a nw en de te n, w er de n au fg ef üh rt . D er B ei tr ag s te llt fe st , d as s a lle d re i S ta nd or te de r S tu di e da s P ro je kt m it Ve rw en du ng sr at en v on V er hü tu ng sm it te ln v on fa st 6 0 Pr oz en t o de r h öh er a bs ch lo ss en . D er B ei tr ag li ef er t k ei ne A ng ab en d ar üb er , a us w ie v ie le n Pe rs on en d ie Er ge bn is an te ile b es ta nd en . D er B ei tr ag b er ic ht et fe rn er , d as s d ie e rz ie lte n Ve rw en du ng sr at en v on V er hü tu ng sm it te ln e in er d ur ch sc hn it tli ch en S te ig er un g vo n 78 P ro ze nt e nt sp re ch en . Al le rd in gs is t n ic ht k la r, w ie d ie se S te ig er un g be re ch ne t w ur de . 3 Pa xm an e t a l., 2 00 5 4 Be i d ie se r S tu di e w ur de n di e Ba si sm es su ng en d re i M on at e na ch B eg in n de r P ro gr am m e du rc hg ef üh rt . E s w ur de n un te rs ch ie dl ic he M et ho de n an d en d re i S ta nd or te n de r S tu di e ve rw en de t. D am it w ur de d ie M ög lic hk ei t e in ge sc hr än kt , d ie E rg eb ni ss e zu sa m m en zu fü hr en 6. In fo rm ie rt e En ts ch ei du ng sfi nd un g Em pf eh lu ng en 6 .1 u nd 6 .2 b er uh en a uf M en sc he nr ec ht sn or m en (A nh an g D ). D ah er w ur de k ei ne g es un dh ei tli ch e Ev id en z ge su ch t. 7. Pr iv at sp hä re u nd V er tr au lic hk ei t Em pf eh lu ng 7. 1 be ru ht a uf M en sc he nr ec ht sn or m en (A nh an g D ). D ah er w ur de k ei ne g es un dh ei tli ch e Ev id en z ge su ch t. 8. T ei ha be Em pf eh lu ng 8 .1 Au to rin : P . W hy te D at um : 1 0. M är z 20 13 Fr ag e: S ol lte e in P ro gr am m zu r F ör de ru ng ö rt lic he r I ni tia tiv en b ei B ew oh ne rn in N or di nd ie n ei ng es et zt w er de n? 1 Se tt in gs : I nd ie n Bi bl io gr ap hi e: 41 Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt *in ne n Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er - ru ng sr is ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Em po w er m en t vo n G em ei nd e- ge su nd he it s- he lfe rin ne n Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t Ve rw en du ng v on V er hü tu ng sm it te ln 11 Be ob ac h tu ng ss tu di en ke in er ns th af te s Ve rz er ru ng sr is ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t2 ke in e 13 0/ 24 1 (5 3, 9% )3 – – – se hr ni ed rig be de ut en d 0 % – Zu fr ie de nh ei t m it B er at un g 12 Be ob ac h tu ng ss tu di en ke in er ns th af te s Ve rz er ru ng sr is ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it er ns th af t2 ke in e 18 8/ 24 1 (7 8% ) – O R 1, 98 (1 ,0 8 bi s 3, 61 )5 – se hr ni ed rig be de ut en d 0 % – 1 Sh re st ha 2 00 2 2 D ie b ew er te te S tic hp ro be w ar k le in (n =2 41 ). 3 Es h an de lt si ch h ie r u m e in e si gn ifi ka nt e St ei ge ru ng g eg en üb er d em B eg in n de r I nt er ve nt io n, a ls k ei ne d er T ei ln eh m er in ne n Ve rh üt un g an w en de te . Au to rin : P . W hy te D at um : 1 0. M är z 20 13 Fr ag e: S ol lte n M aß na hm en zu m E m po w er m en t v on G em ei nd eg es un dh ei ts he lfe rin ne n be i v er he ira te te n Fr au en im g eb är fä hi ge n Al te r d ur ch ge fü hr t w er de n? Se tt in gs : N ep al Bi bl io gr ap hi e: 42 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Q ua lit ät sb eu rt ei lu ng An za hl d er P at ie nt in ne n un d Pa tie nt en Eff ek t Q ua lit ät Be de ut un g An za hl de r St ud ie n D es ig n Ve rz er ru ng s- ris ik o In ko ns is te nz In di re kt he it U ng en au ig ke it W ei te re Fa kt or en Be za hl un g ei ne s ge w in no rie nt ie rt en U nt er ne hm en s f ür di e Be re it st el lu ng v on Fa m ili en pl an un gs - di en st en Ko nt ro lle Re la tiv (9 5 % C I) Ab so lu t An za hl d er F am ili en pl an un gs kl ie nt in ne n/ -k lie nt en 11 Be ob ac h tu ng s st ud ie n ke in er ns th af te s Ve rz er ru ng s ris ik o ke in e er ns th af te In ko ns is te nz ke in e er ns th af te In di re kt he it ke in e er ns th af te U ng en au ig ke it ke in e 3 – – – ni ed rig be de ut en d 0 % – 1 Ch ee e t a l., 2 00 3 2 Ko st en -W irk sa m ke it- An al ys e 3 Zw is ch en 1 99 5 un d 20 00 b et ru g di e An za hl d er F am ili en pl an un gs kl ie nt in ne n un d -k lie nt en 2 84 6. D av on w ar en 4 49 n eu e Fa m ili en pl an un gs ab ne hm er in ne n un d -a bn eh m er u nd 2 39 7 be st eh en - de N ut ze rin ne n un d N ut ze r. D er B ei tr ag b ew er te t d ie V er w en du ng v on V er hü tu ng sm it te ln n ic ht , s on de rn fo ku ss ie rt si ch a uf d ie K os te ne ffi zi en z. A uf d er B as is d es E nd pu nk ts „P aa rv er hü tu ng s- ja hr e“ (C YP ) z ei gt d ie A na ly se , d as s d ie In te rv en tio n Fa m ili en pl an un gs en dp un kt e ko st en fr ei o de r k os te ng ün st ig ($ 0, 00 b is $ 4, 11 ) p ro du zi er en w ür de . D ie K os te n pr o ne ue A bn eh m er in /n eu en Ab ne hm er re ic ht en v on $ 0, 00 b is $ 17 ,9 5. D er B ei tr ag k om m t z u de m S ch lu ss , d as s d ie B ez ah lu ng e in es g ew in no rie nt ie rt en U nt er ne hm en s f ür d ie B er ei ts te llu ng v on F am ili en pl an un gs di en st en ei ne k os te ne ffi zi en te M ög lic hk ei t s ei , u m d ie A nz ah l d er n eu en F am ili en pl an un gs ab ne hm er in ne n un d -a bn eh m er n zu e rh öh en . 9. R ec he ns ch af ts pfl ic ht Em pf eh lu ng en 9 .1 u nd 9 .2 b er uh en a uf M en sc he nr ec ht sn or m en (A nh an g D ). D ie S uc he n ac h Ev id en z be zü gl ic h le is tu ng sb as ie rt er F in an zi er un g er ga b ei ne S tu di e vo n ni ed rig er Q ua lit ät . E in B ed ar f a n Fo rs ch un g üb er d ie W irk sa m ke it de r Au sw irk un g vo n le is tu ng sb as ie rt er F in an zi er un g au f d ie V er fü gb ar ke it vo n Ve rh üt un gs m it te ln so w ie a uf d ie M en sc he nr ec ht e w ur de fe st ge st el lt. Em pf eh lu ng 8 .1 Au to rin : P . W hy te D at um : : 1 1. A pr il 20 13 Fr ag e: S ol lte n fin an zi el le M it te l a uf ge w en de t w er de n, u m e in g ew in no rie nt ie rt es U nt er ne hm en d af ür zu b ez ah le n, F am ili en pl an un gs di en st e be re itz us te lle n? Se tt in gs : K en ia Bi bl io gr ap hi e: 43 Anhang D Gesundheitsstandards und Menschenrechtsnormen Menschenrecht Empfehlungen an die Staaten, die für die Familienplanung von Relevanz sind Das Recht auf eine freiwillige Eheschließung sowie auf Gleichberechtigung in der Ehe • Stellen Sie das Recht sicher, einen Ehepartner/eine Ehepartnerin frei zu wählen und eine Ehe nur aus freien Stücken einzugehen.1 Schaffen Sie alle Erfordernisse der Zustimmung des Ehegatten zum Zugang zu Familien- planungsdiensten ab.2 Das Recht auf Bildung • Familienplanungsdienste sollten innerhalb von umfassenden Diensten im Bereich der sexuellen und reproduktiven Gesundheit angesiedelt sein und auch Sexualaufklärung, einschließlich Beratung, umfassen.3 • Stellen Sie das Recht von Frauen sicher, frei und verantwortungsvoll über die Anzahl ihrer Kinder und die Abstände zwischen den Geburten zu entschei- den sowie ihr Recht auf Zugang zu den Informationen, der Aufklärung und den Mitteln, die sie benötigen, um diese Rechte wahrzunehmen.4 • Stellen Sie den Zugang zu speziellen Aufklärungsinformationen bereit, einschließlich Informationen und Beratung zur Familienplanung, um dazu beizutragen, die Gesundheit und das Wohlbefinden von Familien sicher- zustellen.5 Das Recht auf Gleichheit und Nichtdiskriminierung • Ergreifen Sie alle angemessenen Maßnahmen, um die Diskriminierung von Frauen im Bereich der Gesundheitsversorgung zu beseitigen, um auf der Grundlage der Gleichheit von Männern und Frauen den Zugang zu Gesund- heitsdiensten, einschließlich Familienplanung, sicherzustellen.6 • Staaten sollten alle angemessenen Maßnahmen zur Beseitigung der Diskriminierung von benachteiligten Frauen im Hinblick auf den Zugang zu Gesundheitsversorgung ergreifen, einschließlich Informationen, Beratung und Diensten im Bereich der Familienplanung.7 • Staaten sollten über die Maßnahmen berichten, die sie ergriffen haben, um Hindernisse zu beseitigen, mit denen Frauen beim Zugang zu Gesundheits- diensten konfrontiert sind, sowie über die Maßnahmen, die sie ergriffen haben, um Frauen einen zeitnahen und erschwinglichen Zugang zu solchen Diensten zu ermöglichen. Zu diesen Hindernissen gehören Erfordernisse oder Bedingungen, die den Zugang von Frauen beeinträchtigen, wie zum Bei- spiel hohe Gebühren für Gesundheitsdienste, das Erfordernis der vor herigen Zustimmung des Ehegatten, eines Elternteils oder der Krankenhaus- behörden, die Entfernung zu Gesundheitseinrichtungen sowie das Fehlen bequemer und erschwinglicher öffentlicher Verkehrsmittel.8 • Stellen Sie den Zugang zu qualitativ hochwertigen Gesundheitsdiensten, einschließlich Familienplanung, für alle Frauen, einschließlich weiblicher Jugendlicher, sicher. Diese Gesundheitsdienste sollten in einer Art und Weise erbracht werden, die sicherstellt, dass Frauen in voller Kenntnis der Sachlage Entscheidungen treffen können und dass ihre Würde geachtet, ihre Ver- traulichkeit gewährleistet und ihren Bedarfen und Sichtweisen Rechnung getragen wird.9 • Die gleichberechtigte Beteiligung von Frauen und Männern an allen Verantwortungsbereichen im Haushalt, einschließlich Familienplanung, sollte von Regierungen gefördert und ermutigt werden.10 44 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Menschenrecht Empfehlungen an die Staaten, die für die Familienplanung von Relevanz sind Das Recht auf Gesundheit • Sichern Sie die Verfügbarkeit, Zugänglichkeit, Akzeptanz und Qualität der Informationen und Dienste im Bereich der Familienplanung.12 • Stellen Sie sicher, dass Familienplanungsprogramme zugängliche, voll- ständige und genaue Informationen über verschiedene Methoden der Familienplanung bereitstellen, einschließlich Informationen über deren gesundheitliche Risiken und gesundheitlichen Nutzen, deren mögliche Nebenwirkungen sowie deren Wirksamkeit zur Verhinderung der Aus- breitung von HIV/AIDS und anderen sexuell übertragbaren Krankheiten.13 • Stellen Sie sicher, dass Gesundheitseinrichtungen, -produkte und -dienste, einschließlich Familienplanung, ohne Diskriminierung aus den besagten unzulässigen Gründen für alle Menschen zugänglich sind, insbesondere für die gesetzlich und faktisch schutzbedürftigsten oder marginalisierten Bevöl- kerungsgruppen.14 Das Recht auf Information und freie Meinungsäußerung • Stellen Sie sicher, dass Frauen und Männer Informationen und Zugang zu der breitestmöglichen Palette von sicheren und wirksamen Methoden der Familienplanung haben, damit sie freie und informierte Entscheidungen treffen können.15 • Stellen Sie zugängliche, umfassende Informationen zur Familienplanung bereit, um den Menschen aufzuzeigen, welche Optionen es gibt. Um informierte Entscheidungen über sichere und zuverlässige Verhütungsmittel treffen zu können, müssen Frauen über Informationen über Verhütungs- mittel und deren Verwendung verfügen und einen garantierten Zugang zu Sexualaufklärungs- und Familienplanungsdiensten haben, wie in Artikel 10 (h) des Übereinkommens [der Vereinten Nationen zur Beseitigung der Diskriminierung der Frau] festgelegt ist.16 Das Recht auf Freiheit und Sicherheit der Person • Stellen Sie sicher, dass keine Person willkürlichen oder unrechtmäßigen Eingriffen in ihre Privatsphäre, ihre Familie, ihre Wohnung oder ihre Korrespondenz ausgesetzt wird, einschließlich Eingriffen in Entscheidungen bezüglich der Familienplanung.17 • Stellen Sie sicher, dass keine Person unrechtmäßigen Angriffen auf ihre Ehre oder ihr Ansehen aufgrund von Entscheidungen bezüglich der Familien- planung ausgesetzt wird.18 Das Recht auf Leben • Stellen Sie die Verhütung ungewollter Schwangerschaften durch Familienplanung und Sexualaufklärung sicher und reduzieren Sie die Müt- tersterblichkeit durch sichere Mutterschaftsdienste und vorgeburtliche Hilfe.19 Das Recht, nicht der Folter oder einer anderen grausa- men, unmenschlichen oder erniedrigenden Behandlung oder Strafe unterworfen zu werden • Stellen Sie sicher, dass Maßnahmen ergriffen werden, um die Ausübung von Zwang im Zusammenhang mit Fruchtbarkeit und Fortpflanzung zu verhin- dern.20 • Gewährleisten Sie das Recht, Entscheidungen bezüglich der Fortpflanzung, einschließlich Familienplanung, ohne Diskriminierung, Zwang und Gewalt zu treffen, so wie es in Menschenrechtsdokumenten festgelegt ist.21 45 Menschenrecht Empfehlungen an die Staaten, die für die Familienplanung von Relevanz sind Das Recht, sich an der Gestaltung der öffentlichen Angelegen- heiten zu beteiligen sowie das Recht auf freie, aktive und sinnvolle Teilhabe • Stellen sie die freie, aktive und informierte Beteiligung von Menschen an der Entscheidungsfindung bezüglich der Familienplanung sicher. Programme der reproduktiven Gesundheitsversorgung sollten so gestaltet sein, dass sie den Bedarfen von Frauen, einschließlich weiblichen Jugendlichen, gerecht werden, und sie müssen Frauen in die Leitung, die Planung, den Entschei- dungsprozess, die Umsetzung, die Organisation und die Evaluierung von Diensten einbeziehen.22 • Stellen Sie sicher, dass besondere Anstrengungen unternommen werden, um die Mitverantwortung der Männer hervorzuheben und ihre aktive Beteiligung an verantwortungsvoller Elternschaft, verantwortungsvollem sexuellem und reproduktivem Verhalten, einschließlich Familienplanung, zu fördern.23 Das Recht auf Privatsphäre • Stellen Sie sicher, dass die Zugänglichkeit von Informationen das Recht auf vertrauliche Behandlung von personenbezogenen Gesundheitsdaten, einschließlich Informationen bezüglich der Familienplanung, nicht beeinträchtigt.24 • Stellen Sie sicher, dass alle Gesundheitseinrichtungen, -produkte und -dienste, einschließlich Familienplanung, so gestaltet sind, dass sie die Vertraulichkeit der Betroffenen achten und deren Gesundheitszustand ver- bessern.25 • Die Verwirklichung des Rechts von Jugendlichen auf Gesundheit setzt die Entwicklung jugendfreundlicher Gesundheitsversorgung voraus, die die Vertraulichkeit und die Privatsphäre achtet und angemessene Dienste im Bereich der sexuellen Gesundheit umfasst.26 Das Recht des Einzelnen, über die Anzahl seiner Kinder und die Geburtenabstände zu entscheiden • Stellen Sie sicher, dass [Frauen und Männer] dieselben Rechte haben, frei und verantwortungsvoll über die Anzahl ihrer Kinder und die Abstände zwischen den Geburten zu entscheiden, und dass sie Zugang zu den Informationen, der Aufklärung und den Mitteln haben, die sie benötigen, um diese Rechte wahrzunehmen.27 • Stellen Sie sicher, dass keine Zwangssterilisierungen oder -abtreibungen im Rahmen der Familienplanung stattfinden, da sie sich negativ auf die körper- liche und psychische Gesundheit von Frauen auswirken und das Recht von Frauen verletzen, über die Anzahl ihrer Kinder und die Abstände zwischen den Geburten zu entscheiden.28 • Stellen Sie sicher, dass die Entscheidung für oder gegen Kinder, wenngleich sie am besten in Abstimmung mit dem Ehepartner oder dem Lebens- gefährten erfolgen sollte, nicht durch den Ehepartner, einen Elternteil, den Lebensgefährten oder die Regierung eingeschränkt wird.29 46 Sicherstellung der Menschenrechte im Bereich der Empfängnisverhütung Menschenrecht Empfehlungen an die Staaten, die für die Familienplanung von Relevanz sind Das Recht, frei zu sein von Praktiken, die Frauen und Mädchen schaden • Stellen Sie sicher, dass schädliche soziale oder traditionelle Praktiken den Zugang zu Schwangerschaftsvor- und -nachsorge und Familienplanung nicht behindern. Hindern Sie Dritte daran, Frauen zu zwingen, sich traditionellen Praktiken, wie zum Beispiel der Genitalverstümmelung, zu unterziehen. Ergreifen Sie Maßnahmen, um alle schutzbedürftigen oder marginalisierten gesellschaftlichen Gruppen, insbesondere Frauen, Kinder, Jugendliche und ältere Menschen, angesichts geschlechtsspezifischer Gewaltäußerungen zu schützen.30 Das Recht, frei von Gewalt zu sein • Staaten sollten angemessene und wirksame Maßnahmen ergreifen, um alle Formen geschlechtsspezifischer Gewalt, einschließlich sexueller Gewalt und aller anderen Formen der Gewalt im Zusammenhang mit der Familien- planung, zu überwinden.31 • Stellen Sie sicher, dass Rechtsvorschriften erlassen und wirksam durch- gesetzt werden und dass Politiken, einschließlich Protokolle im Bereich der Gesundheitsversorgung und Familienplanungsprogramme, formuliert werden, um Gewalt gegen Frauen und den Missbrauch von weiblichen Kindern zu bekämpfen und angemessene Gesundheitsdienste bereitzu- stellen.32 • Ergreifen Sie vorbeugende und fördernde Maßnahmen sowie Abhilfe- maßnahmen, um Frauen vor den Auswirkungen schädlicher traditioneller kultureller Praktiken und Normen zu schützen, die ihnen ihre vollen reproduktiven Rechte vorenthalten.33 1. CEDAW Convention on the Elimination of Violence Against Women. Article 16 (B). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 2. CEDAW General Recommendation no. 21 Article 16 (1b) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 3. CRC General Comment no. 15 on the right of the child to the enjoyment of the highest attainable standard of health (art 24 of the International Convention on the Rights of the Child.) New York, UN Committee on the Rights of the Child, 2013. (UN Doc. CRC/C/GC/15) 4. CEDAW Convention on the Elimination of Violence Against Women. (Introduction). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 5. CEDAW Convention on the Elimination of Violence Against Women. Article 10 (h). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 6. CEDAW Convention on the Elimination of Violence Against Women. Article 12 (1). New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 7. CEDAW General Recommendation no. 21 Article 16 (1) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13h Session 1994. 8. General Comment no. 14 Article 12.2 (a). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 9. CEDAW General Recommendation no. 24 Article 12 (1) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 20th Session 1999. 10. Report of the International Conference on Population and Development. Chapter VII, Action 4.26. Cairo, 5-13 September 1994. 11. General Comment no. 14 Article 12.2 (a). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 12. CEDAW General Recommendation no. 24 Article 12 (1) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 13. Report of the International Conference on Population and Development. Chapter VII, Action 7.23 (b). Cairo, 5-13 September 1994. 14. General Comment no. 14 Article 12. The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social, and Cultural Rights). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 15. Report of the International Conference on Population and Development. Chapter VII, Action 7.23 (a). Cairo, 5-13 September 1994. 47 16. CEDAW General Recommendation no. 19 Article 16 (1)(e) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 11th Session 1992. 17. Article 17 of the International Covenant on Civil and Political Rights (CCPR). New York, UN Human Rights Committee, 1976. 19. CEDAW General recommendation for government action no. 13 (c). International Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 13th Session 1994. 20. CEDAW General recommendation no. 19 Article 16 (and 5) of the Convention on the Elimination of Discrimination Against Women. New York, UN Committee on the Elimination of Discrimination Against Women (CEDAW), 11th Session 1992. 21. Report of the International Conference on Population and Development. Chapter V, Action 7.7. Cairo, 5-13 September 1994. 22. Report of the International Conference on Population and Development. Chapter VII, Action 7.3. Cairo, 5-13 September 1994. 23. Report of the International Conference on Population and Development. Chapter VII, Action 4.27. Cairo, 5-13 September 1994. 24. General Comment no. 14 Article 12 (b). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 25. Siehe Quelle 24. 26. General Comment no. 14 Article 12 (no. 23). The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant). New York, UN Committee on Economic, Cultural, and Social Rights (CESCR), 2000. (UN Doc. E/C.12/2000/4) 27. CEDAW Convention on the Elimination of Violence Against Women. Article 16 (1) (e). 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