Family Planning Practices in Developing Countries

*Family Planning and Reproductive Health*

& Personal Care [Internet]. 2019. Available from: https://www.amazon. co.uk/Persona-Contraception-Monitor-Touch-Screen/dp/B01B0OB79W/

[28] Trussell J, Portman D. The creeping pearl: Why has the rate of contraceptive failure increased in clinical trials of combined hormonal contraceptive pills? Contraception. 2013;**88**(5):604-610. DOI: 10.1016/j.

contraception.2013.04.001

[29] Apps on Google Play: OvuView [Internet]. 2019. Available from: https://play.google.com/store/apps/ details?id=com.sleekbit.ovuview

[30] Tayebi N, Yazdanpanahi Z, Yektatalab S, Pourahmad S, Akbarzadeh M. The relationship between body mass index (BMI) and menstrual disorders at different ages of menarche and sex hormones. Journal of the National Medical Association. 2018;**110**(5):440- 447. DOI: 10.1016/j.jnma.2017.10.007

[31] Dunson DB, Baird DD, Colombo B. Increased infertility with age in men and women. Obstetrics and Gynecology.

[32] Rötzer J, Rötzer E. Natürliche Empfängnisregelung—Der

[33] Wink by Kindara: Fertility Awareness Made Simple, Ladyclever [Internet]. 2019. Available from: https:// ladyclever.com/health-fitness/winkby-kindara-fertility-awareness-made-

partnerschaftliche Weg—Die symptothermale Methode. Basel, Wien:

2004;**103**(1):51-56

Freiburg; 2003. pp. 143

simple/

[20] Persona Contraception Monitor | Home Health UK [Internet]. 2019. Available from: https://homehealth-uk. com/all-products/advanced-personaovulation-contraception-monitor/

[21] Cyclotest mySense Bluetooth-Thermometer [Internet]. 2019. Available from: https://www.cyclotest.

[22] Natural Cycles. Contraceptive Methods [Internet]. 2019. Available from: https://www.naturalcycles.com/ birthcontrol/is-natural-cycles-for-me/

mobile app. Contraception.

contraception.2017.08.014

[25] Ducamp M, Lotrea A.

Symptothermal contraception with smartphone apps [Internet]. 2014. Available from: https://sympto.org/3/ en/full-comparative-app-study-of-2014

[26] SymptoPlus record 12 [Internet]. Available from: https://sympto.org/3/ en/full-comparative-app-study-of-2014

[27] Predáč J, Predáčová S. Handbook of Symptothermal Methods NFP and Ecological Breastfeeding. 3rd ed. Olomouc: Liga pár páru v Slovenskej republike; 2014. pp. 181. Available from: https://www.lpp.sk/ponuka/ produkt/7-prirucka-stm-ppr

technique\_en.html

2017;**96**(6):420-425. DOI: 10.1016/j.

[24] Sympto—The natural management of your fertility, online and on mobile phone [Internet]. 2019. Available from: http://www.sympto.ch/

[23] Berglund Scherwitzl E, Lundberg O, Kopp Kallner H, Gemzell Danielsson K, Trussell J, Scherwitzl R. Perfect-use and typical-use Pearl Index of a contraceptive

ref=pd\_bxgy\_img\_2

de/cyclotest-mysense/

**38**

**41**

**Chapter 3**

**Abstract**

Reproductive Health and Family

Looking beyond Individual and

Worldwide, there have been remarkable gains in the provision and utilization of reproductive health and FP services. However, in Africa, despite increasing availability, utilization of these services is less than 50%, even though there are wide variations among and within the countries across the continent. Articles from peer-reviewed journals, technical reports, Internet articles, grey literature (official government documents, technical reports, etc.) and Demographic and Health Survey (DHS) reports were used as resource materials. Manual search of reference list of selected articles was done for further relevant materials. We also used for comparative analysis, the online StatCompiler tool (https://www.statcompiler.com/ en/) to extract data. Reproductive health and contraceptives have a lot of benefits to the individual, family and community. However, despite near universal knowledge and availability of reproductive health and FP services in Africa, utilization of these services is less than optimal. Several factors operating at individual, household and within the community influence utilization of services. These factors are the cause of poor maternal health and care that might hinder population health and the attainment of Sustainable Development Goals (SDGs). Interventions to promote and sustain utilization of services should target these factors at different levels

**Keywords:** antenatal care, facility delivery, skilled attendant, postnatal care, FP,

Inequality in health care utilization and large disparities in health outcomes exists between countries and even within them. These differences largely are defined and perpetrated by a multitude of factors-social structures-and mediated by material and behavioral factors and by aspects of health system delivery [1]. Thirty years after the launch of Safe Motherhood Initiative, the health and wellbeing of mothers and newborns have improved appreciably in many countries. However, countries with the highest burdens of mortality and illness have made least progress and inequalities between countries are increasing. Worldwide, each year, there are about 3.2 million stillborn babies, 4 million neonatal deaths and

Planning Services in Africa:

Household Factors

*Alhaji A. Aliyu and Tukur Dahiru*

depending upon relative role/s of these factors.

service utilization, SSA

**1. Introduction**

#### **Chapter 3**

## Reproductive Health and Family Planning Services in Africa: Looking beyond Individual and Household Factors

*Alhaji A. Aliyu and Tukur Dahiru*

### **Abstract**

Worldwide, there have been remarkable gains in the provision and utilization of reproductive health and FP services. However, in Africa, despite increasing availability, utilization of these services is less than 50%, even though there are wide variations among and within the countries across the continent. Articles from peer-reviewed journals, technical reports, Internet articles, grey literature (official government documents, technical reports, etc.) and Demographic and Health Survey (DHS) reports were used as resource materials. Manual search of reference list of selected articles was done for further relevant materials. We also used for comparative analysis, the online StatCompiler tool (https://www.statcompiler.com/ en/) to extract data. Reproductive health and contraceptives have a lot of benefits to the individual, family and community. However, despite near universal knowledge and availability of reproductive health and FP services in Africa, utilization of these services is less than optimal. Several factors operating at individual, household and within the community influence utilization of services. These factors are the cause of poor maternal health and care that might hinder population health and the attainment of Sustainable Development Goals (SDGs). Interventions to promote and sustain utilization of services should target these factors at different levels depending upon relative role/s of these factors.

**Keywords:** antenatal care, facility delivery, skilled attendant, postnatal care, FP, service utilization, SSA

#### **1. Introduction**

Inequality in health care utilization and large disparities in health outcomes exists between countries and even within them. These differences largely are defined and perpetrated by a multitude of factors-social structures-and mediated by material and behavioral factors and by aspects of health system delivery [1]. Thirty years after the launch of Safe Motherhood Initiative, the health and wellbeing of mothers and newborns have improved appreciably in many countries. However, countries with the highest burdens of mortality and illness have made least progress and inequalities between countries are increasing. Worldwide, each year, there are about 3.2 million stillborn babies, 4 million neonatal deaths and

0.5 million maternal deaths [2]. In majority of situations, the deaths are largely preventable [2, 3]. Around 99% of these deaths occurs in developing countries [2] out of which 11–17% of maternal deaths occurs during childbirth and 50–71% of it in the postpartum period [4]. While every pregnancy carries risks [4, 5] that must be addressed by skilled health providers, the timing, spacing and above all, the women's ability to decide when to become pregnant are key to favorable pregnancy outcomes.

Sexual and reproductive health (SRH) is a relatively new concept in the context of the dynamics of contemporary public health issues. It is closely related to the trio of health, population and environment (PHE), the three topmost challenging issues that require global attention for solutions. SRH is significantly influenced by sociocultural, political and religious considerations [6, 7]. The five core components of sexual and reproductive health include among others improvement of antenatal, postnatal, postpartum and newborn care, provision of high-quality services including family planning (FP), etc. Pregnancy is a physiological process of activities in a continuum, each activity (or stage) crucially influenced by the preceding activity (or stage).

It is well recognized that improving the women's chances of surviving pregnancy and child birth relies on their access to reproductive health including FP. And within the continuum of maternity care, antenatal care (ANC) provides an avenue for important health care functions such as health education, health promotion, screening and diagnosis and disease prevention [8]. Studies have reported that ANC alone can reduce maternal mortality by up to 20%, given good quality and regular attendance [4, 9]. Maternal health care services in developing countries have evolved rather slowly. The first intervention to be implemented in a widespread fashion within maternal health programs was antenatal care. Delivery care (either institutional or home-based) was a later addition [10], while systematic and regular postpartum follow-up and care are hardly available [11]. Poor maternal health thus remains a major reproductive health concern in most part of the developing nations including SSA. Relatively less progress has been made in the area of maternal health compared to the reductions in fertility and infant mortality [12]. It has been estimated that in 2009, the lifetime risk of maternal death in SSA was 1 in 16 (compared to 1 in 2800 in developed regions) and that maternal mortality ratios were 540 in Ghana, 1000 in Kenya, 800 in Nigeria and 880 in Uganda, respectively [13, 14]. The sad reality of the situation is that these deaths can be prevented by simple and cost-effective public health interventions such as giving pregnant women tetanus toxoid injections together with other antenatal care services as well as postnatal care. Because women comprise more than half of the total population of most SSA countries, poor maternal health and care can be a huge obstacle to human and sustainable socio-economic development.

Access to reproductive health services is skewed in favor of urban areas to the detriment of the majority of rural population. Studies have shown how socioeconomic, socio-cultural variables and demographics influenced the demand for and utilization of maternal and child health services [15–17]. For instance, maternal education has been found to be a significant predictor of the use of maternal health care services [18, 19]. Additionally, the costs [20], location [21, 22] and quality of health services are also important. Predictably, these factors interact in different ways to determine the use of health care. Thus, many women in SSA have unmet need for contraceptive and reproductive health services. Unmet reproductive health needs exist if there is a gap between a perceived need and the current available options to satisfy the need [23].

Family planning (FP) for the purpose of child spacing is not alien to African culture. Traditionally, African mothers practice intensive breastfeeding lasting

**43**

visits [32, 33].

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

longer than 24 months (and in some cultures up to 36 months). Some African societies practice postpartum marital sexual separation where the woman spends most of the postpartum period with her parents receiving special traditional and cultural rites for health and vitality [24]. This long period of voluntary separation ensures that sexual intercourse does not happen to avoid pregnancy. However, modern family planning programs, that is, organized effort to provide contraception to women and men, appeared on the sub-continent in 1950s. During the 1950s, there were attempts to establish family planning programs across the region. First, it was in Rhodesia in 1955, then Uganda in 1956, then Kenya in 1957, Mauritius in 1957, Nigeria in 1958 and Sierra Leone in 1959 [25]. By mid-1960s, family planning clinics were scattered across some of these countries offering family planning commodities. Thus, family planning clinics sprang up in the major cities such as Salisbury (Zimbabwe), Nairobi (Kenya), Kampala (Uganda), Lagos and Ibadan (Nigeria), Freetown (Liberia) and Accra (Ghana). Though these family planning clinics were established either by the government or by private associations, there was vehement resistance coming from both the religious and cultural institutions. The landscape remained the same well into 1970s with many countries in this region showing lackadaisical attitudes toward expansion of the services, with quite a handful of these governments indicating that they are not worried about the rate of population growth. However, this position began to change by early 1980s with a global economic meltdown and these governments actively saw the need to intervene to bring down fertility rate via vigorous family planning programs. Since a woman's overall reproductive health is determined collectively by the overall coverage, context, quality and utilization, it is important to assess the levels, trends and barriers of service utilization. Understanding the determinants that affect the utilization of these important reproductive health and FP services can assist in developing policies and designing interventions aimed at improving service utilization in countries across SSA. This will go a long way in

Antenatal care (ANC) basically means care before birth. The aim of ANC is to assist pregnant women to remain healthy, finding and correcting adverse conditions when present and aiding the health of the unborn baby [26]. Within the continuum of maternity care, ANC provides a platform for critical health care functions. These include health promotion, screening and diagnosis and disease prevention [8]. Studies have reported that ANC alone can reduce maternal mortality by 20% with regular attendance and of good quality [4, 9]. Research has shown that achieving the World Health Organization (WHO) recommended four individualized ANC visits at 90% coverage rate could save about 37–71% [27] of newborn deaths, and 67% of death of newborns in SSA could be prevented by high average of care [28]. It also provides an avenue for encouraging skilled attendance at birth [29], early detection and management of potential complications [30] and provision of health education on good nutrition, family planning and breastfeeding [31, 32]. ANC during pregnancy has a positive influence on the utilization of postnatal health care services. The developed world has achieved remarkable success in ANC coverage with over 80% of woman having at least one ANC visit. However, many countries in SSA still have less impressive levels below the WHO recommended four or more visits. In most situations, the women in SSA wait till second or third trimester to make the initial ANC visit, thereby reducing the chances of making at least four

*DOI: http://dx.doi.org/10.5772/intechopen.92138*

reducing maternal mortality.

**2. Reproductive health: antenatal care**

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

longer than 24 months (and in some cultures up to 36 months). Some African societies practice postpartum marital sexual separation where the woman spends most of the postpartum period with her parents receiving special traditional and cultural rites for health and vitality [24]. This long period of voluntary separation ensures that sexual intercourse does not happen to avoid pregnancy. However, modern family planning programs, that is, organized effort to provide contraception to women and men, appeared on the sub-continent in 1950s. During the 1950s, there were attempts to establish family planning programs across the region. First, it was in Rhodesia in 1955, then Uganda in 1956, then Kenya in 1957, Mauritius in 1957, Nigeria in 1958 and Sierra Leone in 1959 [25]. By mid-1960s, family planning clinics were scattered across some of these countries offering family planning commodities. Thus, family planning clinics sprang up in the major cities such as Salisbury (Zimbabwe), Nairobi (Kenya), Kampala (Uganda), Lagos and Ibadan (Nigeria), Freetown (Liberia) and Accra (Ghana). Though these family planning clinics were established either by the government or by private associations, there was vehement resistance coming from both the religious and cultural institutions. The landscape remained the same well into 1970s with many countries in this region showing lackadaisical attitudes toward expansion of the services, with quite a handful of these governments indicating that they are not worried about the rate of population growth. However, this position began to change by early 1980s with a global economic meltdown and these governments actively saw the need to intervene to bring down fertility rate via vigorous family planning programs. Since a woman's overall reproductive health is determined collectively by the overall coverage, context, quality and utilization, it is important to assess the levels, trends and barriers of service utilization. Understanding the determinants that affect the utilization of these important reproductive health and FP services can assist in developing policies and designing interventions aimed at improving service utilization in countries across SSA. This will go a long way in reducing maternal mortality.

#### **2. Reproductive health: antenatal care**

Antenatal care (ANC) basically means care before birth. The aim of ANC is to assist pregnant women to remain healthy, finding and correcting adverse conditions when present and aiding the health of the unborn baby [26]. Within the continuum of maternity care, ANC provides a platform for critical health care functions. These include health promotion, screening and diagnosis and disease prevention [8]. Studies have reported that ANC alone can reduce maternal mortality by 20% with regular attendance and of good quality [4, 9]. Research has shown that achieving the World Health Organization (WHO) recommended four individualized ANC visits at 90% coverage rate could save about 37–71% [27] of newborn deaths, and 67% of death of newborns in SSA could be prevented by high average of care [28]. It also provides an avenue for encouraging skilled attendance at birth [29], early detection and management of potential complications [30] and provision of health education on good nutrition, family planning and breastfeeding [31, 32]. ANC during pregnancy has a positive influence on the utilization of postnatal health care services. The developed world has achieved remarkable success in ANC coverage with over 80% of woman having at least one ANC visit. However, many countries in SSA still have less impressive levels below the WHO recommended four or more visits. In most situations, the women in SSA wait till second or third trimester to make the initial ANC visit, thereby reducing the chances of making at least four visits [32, 33].

*Family Planning and Reproductive Health*

outcomes.

(or stage).

0.5 million maternal deaths [2]. In majority of situations, the deaths are largely preventable [2, 3]. Around 99% of these deaths occurs in developing countries [2] out of which 11–17% of maternal deaths occurs during childbirth and 50–71% of it in the postpartum period [4]. While every pregnancy carries risks [4, 5] that must be addressed by skilled health providers, the timing, spacing and above all, the women's ability to decide when to become pregnant are key to favorable pregnancy

Sexual and reproductive health (SRH) is a relatively new concept in the context of the dynamics of contemporary public health issues. It is closely related to the trio of health, population and environment (PHE), the three topmost challenging issues that require global attention for solutions. SRH is significantly influenced by sociocultural, political and religious considerations [6, 7]. The five core components of sexual and reproductive health include among others improvement of antenatal, postnatal, postpartum and newborn care, provision of high-quality services including family planning (FP), etc. Pregnancy is a physiological process of activities in a continuum, each activity (or stage) crucially influenced by the preceding activity

It is well recognized that improving the women's chances of surviving pregnancy and child birth relies on their access to reproductive health including FP. And within the continuum of maternity care, antenatal care (ANC) provides an avenue for important health care functions such as health education, health promotion, screening and diagnosis and disease prevention [8]. Studies have reported that ANC alone can reduce maternal mortality by up to 20%, given good quality and regular attendance [4, 9]. Maternal health care services in developing countries have evolved rather slowly. The first intervention to be implemented in a widespread fashion within maternal health programs was antenatal care. Delivery care (either institutional or home-based) was a later addition [10], while systematic and regular postpartum follow-up and care are hardly available [11]. Poor maternal health thus remains a major reproductive health concern in most part of the developing nations including SSA. Relatively less progress has been made in the area of maternal health compared to the reductions in fertility and infant mortality [12]. It has been estimated that in 2009, the lifetime risk of maternal death in SSA was 1 in 16 (compared to 1 in 2800 in developed regions) and that maternal mortality ratios were 540 in Ghana, 1000 in Kenya, 800 in Nigeria and 880 in Uganda, respectively [13, 14]. The sad reality of the situation is that these deaths can be prevented by simple and cost-effective public health interventions such as giving pregnant women tetanus toxoid injections together with other antenatal care services as well as postnatal care. Because women comprise more than half of the total population of most SSA countries, poor maternal health and care can be a huge obstacle to

Access to reproductive health services is skewed in favor of urban areas to the detriment of the majority of rural population. Studies have shown how socioeconomic, socio-cultural variables and demographics influenced the demand for and utilization of maternal and child health services [15–17]. For instance, maternal education has been found to be a significant predictor of the use of maternal health care services [18, 19]. Additionally, the costs [20], location [21, 22] and quality of health services are also important. Predictably, these factors interact in different ways to determine the use of health care. Thus, many women in SSA have unmet need for contraceptive and reproductive health services. Unmet reproductive health needs exist if there is a gap between a perceived need and the current available

Family planning (FP) for the purpose of child spacing is not alien to African culture. Traditionally, African mothers practice intensive breastfeeding lasting

human and sustainable socio-economic development.

**42**

options to satisfy the need [23].

Several studies have assessed individual and household determinants in the utilization of reproductive health services in SSA. For instance, socio-demographic, religion, accessibility, educational status and affordability (socio-economic status) [12, 34–38] were all found to determine antenatal care utilization. The influence of these factors varied between countries across the continent. In Zimbabwe, poor quality of care and attitudes of service providers were barriers to utilization of services [39]. It can be assumed that utilization of maternal health services depends not only on individual and household factors but also importantly within the context of the country where the individual resides. Understanding this context is the key to improving service utilization since the individuals or couples are nested with families, which are in turn nested within communities. Studies have shown that family and community membership constitutes a major determinant in access to ANC services [27, 40].

#### **3. Health facility delivery and skilled attendant at birth**

While motherhood is often a positive and fulfilling experience, for too many women, it is associated with suffering, pain, ill-health and even death. Delivery at a health facility with assistance of skilled medical professional reduces the risk of complications and infections during labor and delivery. Skilled birth attendance is the process by which a woman is provided adequate care by trained health personnel during labor, delivery and early postnatal period. It is the single most cost-effective intervention in reducing maternal and perinatal mortality. In the developing countries, one third of all pregnant women receive no health talk, 60% of all deliveries take place outside health care facilities and about 46.7% of all deliveries are attended to by trained health personnel [41, 42]. Epidemiologic data on maternal deaths in developing countries revealed that two-thirds of death occur around the time of delivery [43]. Obstetric complication can occur around the time of delivery and cannot be predicted. Thus, it is important that all pregnant women have access to a skilled attendant to manage normal delivery and who can also recognize and manage obstetric complications or refer to high-level facility when necessary.

Across the continent, variations exist at individual, household and community contexts on the factors that influence the utilization of these services. Several individual factors that affect the use of ANC significantly influence the use of skilled personnel for delivery. Skilled attendance at delivery is an important factor in preventing maternal deaths and it is also crucial to prevent stillbirths and improve newborn survival [44, 45]. There are wide variations across SSA on health facility delivery and birth attended to by skilled personnel. In Nigeria, health facility delivery (39%) and skilled attendant at delivery (43%) are very low [46]. While in Zimbabwe, 77% of births took place in health facility and about 8 in 10 deliveries are assisted by a skilled provider (majority by a nurse or nurse midwife, 66%) [47]. There has been a progressive remarkable improvement in Ghana, where facility delivery increased from 54% in 2007 to 79% in 2017 and skilled attendant at delivery was 79% [48]. According to recent demographic and health survey (DHS), facility delivery and skilled attendant in Tanzania were respectively 63% and 64% [49]. Previous studies have shown consistent association between urban residence and utilization of ANC, delivery and PNC services [50]. In general, the decisions that lead women to use services seem to reside within the context of their marriage. Since individuals and families all live within the community, it definitely can influence personal health–seeking behavior as there are personnel beliefs and attitudes and community norms [51]. Again, religion and to a large extent ethnicity often influence beliefs, norms and values in relation to pregnancy, childbirth and

**45**

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

is viewed as being necessary to allow access to facility delivery [52].

utilization in Ethiopia [53], 43% in Nigeria [46] to 52% in Kenya [54].

utilization of services [44, 50]. The variations in factors and diversity within the populations of women could be explained by differences in women's autonomy, empowerment, gender relationships and social networks, which are in turn influenced by embedded social structures, religion and cultural beliefs. For instance, non-white South African women usually attend ANC later in pregnancy because it

Even though ANC is universally free in most countries in SSA, this does not translate into use of skilled attendance at delivery, since less than 50% of all women are assisted by skilled professional during delivery. SSA is the region with the lowest coverage of skilled delivery utilization with only 45% of women having skilled attendants at birth [50]. From a country-specific context, there are wide variations across and within the countries across the continent, with 10% skilled delivery

About half of postpartum deaths take place within one day of delivery and roughly 70% occur within the first week. Obviously, there is mismatch between women's need for reproductive health care and what is currently available in terms of its provision and service utilization across SSA. Large body of evidence on factors contributing to poor service utilization consistently showed physical and financial barriers as well as educational level, parity, residence, ANC attendance and social status of the women [50, 55–58]. Expectedly, better educated women and those who had better autonomy in decisions pertaining to household expenses were more likely to have facility delivery [55]. In the context of achieving universal health coverage through improving health systems strengthening, barriers still remain in

Worldwide, about half of maternal deaths occur within the first 24 h after delivery. WHO guidelines that most countries in SSA adopted recommends that women who deliver in a health facility receive postnatal care check in the 24 h after delivery, while those who gave birth outside a health facility should be referred for postnatal checks in health facility within 12 h after delivery. PNC is part of continuum of care started from ANC. Thus, antenatal care promotes the use of PNC services for the mother-child pair [33]. As a major component of PNC, immunization remains to be one of the most effective public health interventions that have been proven to prevent about 24% of the 10 million deaths of children under five years annually [59]. Postnatal care (PNC) is one of the recommended strategies to reduce maternal and newborn deaths during the postpartum period [27, 60]. It is further recommended that mothers and newborns receive PNC in health facilities for at least 24 h after birth for those who delivered in the facility. While for those who delivered outside the health facility (at home), the first postnatal contact should be within 24 h of birth. At least 3 additional postnatal contacts are recommended for both mothers and newborns on day 3 (48–72 h), between days 7 and 14 after birth and 6 weeks after birth [61]. As with other maternal health services, PNC utilization is weak or low in SSA among all reproductive and child health programs. PNC utilization in Ethiopia is very low with only 7.1% of women [50] having PNC service in the first 2 days after delivery, 42% in Nigeria [46], 57% in Zimbabwe [47], 12.8% in Rwanda

[62], 31% in Tanzania [63] and 58% in Uganda [64], respectively.

Again, physical accessibility is one of the most important variables in health service utilization. Several studies have shown that proximity of health care services play an important role in service utilization [21, 50, 65]. A number of individual, household and institutional characteristics affect women's decision in seeking

*DOI: http://dx.doi.org/10.5772/intechopen.92138*

the utilization of reproductive health services.

**4. Postnatal care (PNC)**

#### *Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

utilization of services [44, 50]. The variations in factors and diversity within the populations of women could be explained by differences in women's autonomy, empowerment, gender relationships and social networks, which are in turn influenced by embedded social structures, religion and cultural beliefs. For instance, non-white South African women usually attend ANC later in pregnancy because it is viewed as being necessary to allow access to facility delivery [52].

Even though ANC is universally free in most countries in SSA, this does not translate into use of skilled attendance at delivery, since less than 50% of all women are assisted by skilled professional during delivery. SSA is the region with the lowest coverage of skilled delivery utilization with only 45% of women having skilled attendants at birth [50]. From a country-specific context, there are wide variations across and within the countries across the continent, with 10% skilled delivery utilization in Ethiopia [53], 43% in Nigeria [46] to 52% in Kenya [54].

About half of postpartum deaths take place within one day of delivery and roughly 70% occur within the first week. Obviously, there is mismatch between women's need for reproductive health care and what is currently available in terms of its provision and service utilization across SSA. Large body of evidence on factors contributing to poor service utilization consistently showed physical and financial barriers as well as educational level, parity, residence, ANC attendance and social status of the women [50, 55–58]. Expectedly, better educated women and those who had better autonomy in decisions pertaining to household expenses were more likely to have facility delivery [55]. In the context of achieving universal health coverage through improving health systems strengthening, barriers still remain in the utilization of reproductive health services.

#### **4. Postnatal care (PNC)**

*Family Planning and Reproductive Health*

to ANC services [27, 40].

Several studies have assessed individual and household determinants in the utilization of reproductive health services in SSA. For instance, socio-demographic, religion, accessibility, educational status and affordability (socio-economic status) [12, 34–38] were all found to determine antenatal care utilization. The influence of these factors varied between countries across the continent. In Zimbabwe, poor quality of care and attitudes of service providers were barriers to utilization of services [39]. It can be assumed that utilization of maternal health services depends not only on individual and household factors but also importantly within the context of the country where the individual resides. Understanding this context is the key to improving service utilization since the individuals or couples are nested with families, which are in turn nested within communities. Studies have shown that family and community membership constitutes a major determinant in access

While motherhood is often a positive and fulfilling experience, for too many women, it is associated with suffering, pain, ill-health and even death. Delivery at a health facility with assistance of skilled medical professional reduces the risk of complications and infections during labor and delivery. Skilled birth attendance is the process by which a woman is provided adequate care by trained health personnel during labor, delivery and early postnatal period. It is the single most cost-effective intervention in reducing maternal and perinatal mortality. In the developing countries, one third of all pregnant women receive no health talk, 60% of all deliveries take place outside health care facilities and about 46.7% of all deliveries are attended to by trained health personnel [41, 42]. Epidemiologic data on maternal deaths in developing countries revealed that two-thirds of death occur around the time of delivery [43]. Obstetric complication can occur around the time of delivery and cannot be predicted. Thus, it is important that all pregnant women have access to a skilled attendant to manage normal delivery and who can also recognize and manage obstetric complications or refer to high-level facility when necessary.

Across the continent, variations exist at individual, household and community

contexts on the factors that influence the utilization of these services. Several individual factors that affect the use of ANC significantly influence the use of skilled personnel for delivery. Skilled attendance at delivery is an important factor in preventing maternal deaths and it is also crucial to prevent stillbirths and improve newborn survival [44, 45]. There are wide variations across SSA on health facility delivery and birth attended to by skilled personnel. In Nigeria, health facility delivery (39%) and skilled attendant at delivery (43%) are very low [46]. While in Zimbabwe, 77% of births took place in health facility and about 8 in 10 deliveries are assisted by a skilled provider (majority by a nurse or nurse midwife, 66%) [47]. There has been a progressive remarkable improvement in Ghana, where facility delivery increased from 54% in 2007 to 79% in 2017 and skilled attendant at delivery was 79% [48]. According to recent demographic and health survey (DHS), facility delivery and skilled attendant in Tanzania were respectively 63% and 64% [49]. Previous studies have shown consistent association between urban residence and utilization of ANC, delivery and PNC services [50]. In general, the decisions that lead women to use services seem to reside within the context of their marriage. Since individuals and families all live within the community, it definitely can influence personal health–seeking behavior as there are personnel beliefs and attitudes and community norms [51]. Again, religion and to a large extent ethnicity often influence beliefs, norms and values in relation to pregnancy, childbirth and

**3. Health facility delivery and skilled attendant at birth**

**44**

Worldwide, about half of maternal deaths occur within the first 24 h after delivery. WHO guidelines that most countries in SSA adopted recommends that women who deliver in a health facility receive postnatal care check in the 24 h after delivery, while those who gave birth outside a health facility should be referred for postnatal checks in health facility within 12 h after delivery. PNC is part of continuum of care started from ANC. Thus, antenatal care promotes the use of PNC services for the mother-child pair [33]. As a major component of PNC, immunization remains to be one of the most effective public health interventions that have been proven to prevent about 24% of the 10 million deaths of children under five years annually [59]. Postnatal care (PNC) is one of the recommended strategies to reduce maternal and newborn deaths during the postpartum period [27, 60]. It is further recommended that mothers and newborns receive PNC in health facilities for at least 24 h after birth for those who delivered in the facility. While for those who delivered outside the health facility (at home), the first postnatal contact should be within 24 h of birth. At least 3 additional postnatal contacts are recommended for both mothers and newborns on day 3 (48–72 h), between days 7 and 14 after birth and 6 weeks after birth [61]. As with other maternal health services, PNC utilization is weak or low in SSA among all reproductive and child health programs. PNC utilization in Ethiopia is very low with only 7.1% of women [50] having PNC service in the first 2 days after delivery, 42% in Nigeria [46], 57% in Zimbabwe [47], 12.8% in Rwanda [62], 31% in Tanzania [63] and 58% in Uganda [64], respectively.

Again, physical accessibility is one of the most important variables in health service utilization. Several studies have shown that proximity of health care services play an important role in service utilization [21, 50, 65]. A number of individual, household and institutional characteristics affect women's decision in seeking

health care. In general, despite the availability of reproductive health services, the decisions that lead women to use the services resides within the context of their marriage, household and family/community settings. The use of ANC during pregnancy is a major predictor of subsequent use of skilled delivery and PNC services. Therefore, the importance of ANC utilization as a key entry point to increase PNC services cannot be overemphasized. The early postpartum period can be targeted as the best period to discuss FP methods with the couples.

#### **5. Family planning: levels of knowledge of contraceptive methods**

Knowledge of at least any modern method among the women is almost universal across the countries (**Table 1**). The earliest information on knowledge of any modern method of contraception is the Nigeria Demographic and Health Survey (DHS) of 1990 and it reported a level of 41.2%, which coincidentally is lowest among the countries, while Burundi reported the highest level of 99.2% in 2016–2017 [66]. The level of knowledge varied markedly among countries with lowest knowledge level of 63.5% reported from Chad DHS of 2014–2015 to the highest (universal) of 100% in Rwanda [66]. In terms of percent change, Comoros recorded the smallest change in knowledge of 0.4%, while Nigeria recorded the highest of 52.7%.

#### **5.1 Levels and trends of ever use of modern contraception**

The level and trend in ever use of modern contraception among the women was reported by 24 countries; many other countries did not collect this information between surveys. Ever use of modern contraception was lowest in Chad, 2.8% (1996/1997 survey) and 5.2% in most recent survey (2004) while Zimbabwe had the highest levels of 85.2% (2005/2006 survey) [47], respectively. Malawi recorded the greatest change (increase) in ever use of modern contraception of 55.4%. There has always being a great gap between knowledge and practice (ever use) of modern contraception particularly in sub-Saharan Africa (**Figure 1**) [67]. The difference between knowledge and ever use of a modern method of contraception is widest in Niger (77.6%) and narrowest in Zimbabwe (14.5%). This is not surprising as Niger Republic is traditionally a high-fertility country coupled with low literacy level, strong cultural and religious opposition to modern contraception and early age at marriage. However, the story is different with Zimbabwe often cited as one of the few success stories in sub-Saharan Africa where family planning services appeared in the country as far back as 1953 coupled with cultural and religious tolerance to its use [68].

#### **5.2 Levels and trends of current use of modern contraception**

Current use of modern contraception among countries in SSA showed variability with Chad having the lowest of 5.0%, while Zimbabwe had the highest at 65.8%. Two countries, Liberia and Senegal, had their earliest DHS to have been conducted in 1986, which showed a very low uptake of modern contraception at 5.5% and 2.1%, respectively. South Africa conducted its earliest DHS in 1998 with an uptake of modern contraception of 55.1%; the same country that conducted its recent DHS in 2016 reported a decline in uptake to 54.0% (or a drop of 1.1%). Malawi recorded the greatest change between its earliest and most recent survey of 50.7% [66]. Again, the greatest disparity between knowledge and current use of modern contraception is as shown in **Figure 2**. Across the globe, this pattern has been reported particularly in developing countries [68].

**47**

**Table 1.**

*1990–2018 [66].*

**5.3 Sources of modern contraceptive methods**

It is generally believed that as the demand for modern contraception increases, the supply as well as outlets will increase and at the same time become diversified [67]. Initially, modern contraception is almost solely provided by government through its formal outlets such as hospitals, family planning clinics, health clinics,

*Percentage of currently married women who know any modern method of contraception, DHS surveys* 

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

 Benin 76.2 96.3 20.1 Burkina Faso 63.3 97.5 34.2 Burundi 99.2 99.7 0.5 Cameroon 62.9 94.0 31.1 Chad 42.8 63.5 20.7 Comoros 98.1 98.5 0.4 Congo 96.3 98.6 2.3 Congo Democratic Republic 76.7 89.9 13.2 Cote d'Ivoire 71.5 93.2 21.7 Eritrea 62.0 87.2 25.2 Ethiopia 85.3 98.7 13.4 Gabon 94.7 97.6 2.9 Ghana 90.7 99.2 8.5 Guinea 69.1 84.8 15.7 Kenya 96.9 98.7 1.8 Lesotho 98.1 99.5 1.4 Liberia 86.7 98.6 11.9 Madagascar 61.7 95.0 33.3 Malawi 91.8 99.6 7.8 Mali 64.6 94.4 29.8 Mozambique 60.4 96.3 35.9 Namibia 90.3 99.8 9.5 Niger 58.0 89.3 31.3 Nigeria 41.2 93.9 52.7 Rwanda 96.8 100.0 3.2 Senegal 70.4 97.2 26.8 Sierra Leone 66.2 93.7 27.5 South Africa 98.0 99.9 1.9 Tanzania 77.6 99.1 21.5 Togo 93.4 97.1 3.7 Uganda 91.6 99.7 8.1 Zambia 90.7 99.7 9.0 Zimbabwe 98.5 99.7 1.2

**Country Earliest Recent Change**

*DOI: http://dx.doi.org/10.5772/intechopen.92138*


*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

#### **Table 1.**

*Family Planning and Reproductive Health*

the best period to discuss FP methods with the couples.

health care. In general, despite the availability of reproductive health services, the decisions that lead women to use the services resides within the context of their marriage, household and family/community settings. The use of ANC during pregnancy is a major predictor of subsequent use of skilled delivery and PNC services. Therefore, the importance of ANC utilization as a key entry point to increase PNC services cannot be overemphasized. The early postpartum period can be targeted as

**5. Family planning: levels of knowledge of contraceptive methods**

in knowledge of 0.4%, while Nigeria recorded the highest of 52.7%.

**5.1 Levels and trends of ever use of modern contraception**

**5.2 Levels and trends of current use of modern contraception**

particularly in developing countries [68].

Current use of modern contraception among countries in SSA showed variability with Chad having the lowest of 5.0%, while Zimbabwe had the highest at 65.8%. Two countries, Liberia and Senegal, had their earliest DHS to have been conducted in 1986, which showed a very low uptake of modern contraception at 5.5% and 2.1%, respectively. South Africa conducted its earliest DHS in 1998 with an uptake of modern contraception of 55.1%; the same country that conducted its recent DHS in 2016 reported a decline in uptake to 54.0% (or a drop of 1.1%). Malawi recorded the greatest change between its earliest and most recent survey of 50.7% [66]. Again, the greatest disparity between knowledge and current use of modern contraception is as shown in **Figure 2**. Across the globe, this pattern has been reported

Knowledge of at least any modern method among the women is almost universal across the countries (**Table 1**). The earliest information on knowledge of any modern method of contraception is the Nigeria Demographic and Health Survey (DHS) of 1990 and it reported a level of 41.2%, which coincidentally is lowest among the countries, while Burundi reported the highest level of 99.2% in 2016–2017 [66]. The level of knowledge varied markedly among countries with lowest knowledge level of 63.5% reported from Chad DHS of 2014–2015 to the highest (universal) of 100% in Rwanda [66]. In terms of percent change, Comoros recorded the smallest change

The level and trend in ever use of modern contraception among the women was reported by 24 countries; many other countries did not collect this information between surveys. Ever use of modern contraception was lowest in Chad, 2.8% (1996/1997 survey) and 5.2% in most recent survey (2004) while Zimbabwe had the highest levels of 85.2% (2005/2006 survey) [47], respectively. Malawi recorded the greatest change (increase) in ever use of modern contraception of 55.4%. There has always being a great gap between knowledge and practice (ever use) of modern contraception particularly in sub-Saharan Africa (**Figure 1**) [67]. The difference between knowledge and ever use of a modern method of contraception is widest in Niger (77.6%) and narrowest in Zimbabwe (14.5%). This is not surprising as Niger Republic is traditionally a high-fertility country coupled with low literacy level, strong cultural and religious opposition to modern contraception and early age at marriage. However, the story is different with Zimbabwe often cited as one of the few success stories in sub-Saharan Africa where family planning services appeared in the country as far back as 1953 coupled with cultural and religious tolerance to its

**46**

use [68].

*Percentage of currently married women who know any modern method of contraception, DHS surveys 1990–2018 [66].*

#### **5.3 Sources of modern contraceptive methods**

It is generally believed that as the demand for modern contraception increases, the supply as well as outlets will increase and at the same time become diversified [67]. Initially, modern contraception is almost solely provided by government through its formal outlets such as hospitals, family planning clinics, health clinics,

**Figure 1.** *Gap between knowledge and ever use of modern contraception, DHS surveys [66].*

**Figure 2.** *Gap between knowledge and current use of modern contraception, DHS surveys [66].*

etc. However, with an increase in demand and acceptance, the sources began to expand and more providers appeared in the market such as private non-governmental organizations and religious and faith-based organizations (**Table 2**). Across sub-Saharan Africa, public outlet is the predominant as well as important source of information on contraception. This is not surprising because of the misconceptions associated with it. It is much later that private medical outlets and then other private non-medical outlets joined the supply and service outlet.

Marked variability exists across the continent on public source as supplier of contraceptive commodity accounting for 20.7% in Democratic Republic of Congo, 91.3% Rwanda and 93.3% Niger, respectively [66]. Regarding the changes in the proportion of public source of information and contraception, Uganda and Madagascar recorded the greatest changes. There was a decline in Uganda, while Madagascar recorded an increase in the role of public outlet of contraception. The reasons for this might be due to influx of other non-public (or governmental) supplies or a decline in quality of services as well as supply of the commodity. For those that recorded an increase in this proportion, probably the government in recent times is becoming more active in FP programs. Decline in the proportion of women obtaining information and contraception from public outlet has been documented earlier [67]. In this analysis, 12 countries (or 38%) experienced a decline in the percentage of women getting contraception from public channels, while in the remaining countries, it increased. Thus, it is reasonable to assume that an expansion of high-quality services might increase women's motivation to use these services.

#### **5.4 Contraceptive discontinuation and switching**

There are several reasons why a woman currently using a modern contraception would discontinue or switch to another method. Some of these reasons could be health-related such as experiencing intolerable side effects (hypertension, obesity, etc.). More often, it is fertility-related such as a desire to become pregnant, or it

**49**

**Table 2.**

barriers to use contraceptives.

*information from a public source, DHS surveys [66].*

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

 Benin 43.5 62.4 18.9 Burkina Faso 64.6 73.7 9.1 Burundi 87.3 80.9 -6.4 Cameroon 30.5 20.0 -10.5 Chad 59.3 71.6 12.3 Comoros 77.6 87.2 9.6 Congo 22.0 19.4 -2.6 Congo Democratic Republic 20.7 31.1 10.4 Cote d'Ivoire 25.5 26.3 0.8 Eritrea 78.4 74.0 -4.4 Ethiopia 77.5 83.8 6.3 Ghana 35.7 63.7 28.0 Guinea 49.9 63.6 13.7 Kenya 70.5 59.9 -10.6 Lesotho 56.7 62.0 5.3 Liberia 50.8 72.3 21.5 Madagascar 38.8 72.8 34.0 Malawi 69.9 79.4 9.5 Mali 52.0 77.2 25.2 Mozambique 82.7 76.6 -6.1 Namibia 86.4 73.7 -12.7 Niger 93.3 85.3 -8.0 Nigeria 37.1 54.3 17.2 Rwanda 69.0 91.3 22.3 Senegal 59.1 86.5 27.4 Sierra Leone 50.4 68.4 18.0 South Africa 83.6 80.4 -3.2 Tanzania 72.9 60.8 -12.1 Togo 41.7 52.9 11.2 Uganda 82.7 58.5 -24.2 Zambia 56.1 81.6 25.5 Zimbabwe 88.9 73.0 -15.9

**Country Earliest Recent Change**

could be due to marital problems such as disapproval by the spouse or economic such as cost or health system factors such as lack of accessibility or availability to continue with the current method. Studies have shown that fear of side effects especially those associated with hormonal contraception has been reported to act as strong barriers [69–72], while other studies revealed fear of infertility, menstrual irregularities, cancer, weight gain [73–76] and spousal communication [77–79] as

*Percentage of women currently using modern contraceptive methods who received their most recent supply or* 

*DOI: http://dx.doi.org/10.5772/intechopen.92138*


*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

#### **Table 2.**

*Family Planning and Reproductive Health*

**Figure 1.**

**Figure 2.**

etc. However, with an increase in demand and acceptance, the sources began to expand and more providers appeared in the market such as private non-governmental organizations and religious and faith-based organizations (**Table 2**). Across sub-Saharan Africa, public outlet is the predominant as well as important source of information on contraception. This is not surprising because of the misconceptions associated with it. It is much later that private medical outlets and then other

Marked variability exists across the continent on public source as supplier of contraceptive commodity accounting for 20.7% in Democratic Republic of Congo, 91.3% Rwanda and 93.3% Niger, respectively [66]. Regarding the changes in the proportion of public source of information and contraception, Uganda and Madagascar recorded the greatest changes. There was a decline in Uganda, while Madagascar recorded an increase in the role of public outlet of contraception. The reasons for this might be due to influx of other non-public (or governmental) supplies or a decline in quality of services as well as supply of the commodity. For those that recorded an increase in this proportion, probably the government in recent times is becoming more active in FP programs. Decline in the proportion of women obtaining information and contraception from public outlet has been documented earlier [67]. In this analysis, 12 countries (or 38%) experienced a decline in the percentage of women getting contraception from public channels, while in the remaining countries, it increased. Thus, it is reasonable to assume that an expansion of high-quality services might increase women's motivation to use these services.

There are several reasons why a woman currently using a modern contraception would discontinue or switch to another method. Some of these reasons could be health-related such as experiencing intolerable side effects (hypertension, obesity, etc.). More often, it is fertility-related such as a desire to become pregnant, or it

private non-medical outlets joined the supply and service outlet.

*Gap between knowledge and current use of modern contraception, DHS surveys [66].*

*Gap between knowledge and ever use of modern contraception, DHS surveys [66].*

**5.4 Contraceptive discontinuation and switching**

**48**

*Percentage of women currently using modern contraceptive methods who received their most recent supply or information from a public source, DHS surveys [66].*

could be due to marital problems such as disapproval by the spouse or economic such as cost or health system factors such as lack of accessibility or availability to continue with the current method. Studies have shown that fear of side effects especially those associated with hormonal contraception has been reported to act as strong barriers [69–72], while other studies revealed fear of infertility, menstrual irregularities, cancer, weight gain [73–76] and spousal communication [77–79] as barriers to use contraceptives.

#### *Family Planning and Reproductive Health*

Sub-Saharan Africa has the highest overall discontinuation rates due to all reasons, ranging from 19.1% in Namibia to 65.5% in Guinea [66]. In this analysis, five out of twelve countries have experienced an increase in discontinuation rates. All except Nigeria with a rate of 13% had these rates less than 5%. Senegal recorded massive decline in discontinuation rate or negative 15.9% (or −15.9%) (**Figure 3**). However, at a global level, the lowest discontinuation is recorded in Papua New Guinea with a rate of rate 15.6% [80].

Concerning method switch, the same twelve countries were involved due to a variety of reasons enumerated above. Four countries recorded increases in the rates of switching, while the remaining experienced declines of up to 6.3% (or −6.3%) (**Table 3**). Rate of discontinuation due to desire to become pregnant declined in three countries, while Nigeria and Republic of Benin recorded the largest increases of up to 4.5% each (**Table 4**).

Discontinuation due to side effects declined in four countries but increased in the remaining eight (**Table 5**). The largest increase was recorded in Nigeria, 5.1%. Discontinuation due to health-related factors could be an indicator of quality of family planning services.

#### **Figure 3.**

*Change in the first-year contraceptive discontinuation rate due to all reasons, DHS surveys.*


#### **Table 3.**

*Percentage of women currently using modern contraceptive methods who discontinued by switching to another method, DHS surveys.*

**51**

**Table 5.**

*surveys.*

**Table 4.**

*pregnant, DHS surveys.*

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

 Benin 7.7 12.2 4.5 Burundi 9.0 9.2 0.2 Ethiopia 10.3 10.8 0.5 Kenya 4.6 4.7 0.1 Malawi 8.4 6.7 −1.7 Mali 13.8 14.8 1.0 Nigeria 8.2 12.7 4.5 Rwanda 2.7 3.9 1.2 Senegal 7.3 6.3 −1.0 Tanzania 8.4 5.1 −3.3 Uganda 7.5 8.8 1.3 Zimbabwe 4.8 5.1 0.3

*Percentage of women currently using modern contraceptive methods who discontinued due to desire to become* 

 Benin 5.9 5.8 −0.1 Burundi 10.6 15.2 4.6 Ethiopia 14.5 7.4 −7.1 Kenya 8.5 10.5 2.0 Malawi 10.5 10.6 0.1 Mali 10.3 10.5 0.2 Nigeria 2.1 7.2 5.1 Rwanda 10.7 10.8 0.1 Senegal 14.2 11.3 −2.9 Tanzania 11.6 9.8 −1.8 Uganda 15.8 18.1 2.3 Zimbabwe 3.6 6.0 2.4

**Country Earliest Recent Change**

**Country Earliest Recent Change**

**6. Factors associated with the use of modern contraception**

grouped into two broad categories:

1.Individual factors

2.Contextual factors

The current body of knowledge is replete with literature on the factors associ-

*Percentage of women currently using modern contraceptive methods who discontinued due to side effects, DHS* 

ated with the use of modern contraception. Systematically, these factors are

*DOI: http://dx.doi.org/10.5772/intechopen.92138*


*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

#### **Table 4.**

*Family Planning and Reproductive Health*

Guinea with a rate of rate 15.6% [80].

of up to 4.5% each (**Table 4**).

family planning services.

Sub-Saharan Africa has the highest overall discontinuation rates due to all reasons, ranging from 19.1% in Namibia to 65.5% in Guinea [66]. In this analysis, five out of twelve countries have experienced an increase in discontinuation rates. All except Nigeria with a rate of 13% had these rates less than 5%. Senegal recorded massive decline in discontinuation rate or negative 15.9% (or −15.9%) (**Figure 3**). However, at a global level, the lowest discontinuation is recorded in Papua New

Concerning method switch, the same twelve countries were involved due to a variety of reasons enumerated above. Four countries recorded increases in the rates of switching, while the remaining experienced declines of up to 6.3% (or −6.3%) (**Table 3**). Rate of discontinuation due to desire to become pregnant declined in three countries, while Nigeria and Republic of Benin recorded the largest increases

Discontinuation due to side effects declined in four countries but increased in the remaining eight (**Table 5**). The largest increase was recorded in Nigeria, 5.1%. Discontinuation due to health-related factors could be an indicator of quality of

**Country Recent Earliest Change** Benin 2.5 1.5 1.0 Burundi 4.6 8.1 −3.5 Ethiopia 5.8 12.1 −6.3 Kenya 10.5 7.0 3.5 Malawi 5.3 3.7 1.6 Mali 1.9 3.4 −1.5 Nigeria 4.5 4.8 −0.3 Rwanda 10.3 10.4 −0.1 Senegal 4.2 5.2 −1.0 Tanzania 6.4 9.4 −3.0 Uganda 5.0 5.2 −0.2 Zimbabwe 6.7 4.2 2.5

*Change in the first-year contraceptive discontinuation rate due to all reasons, DHS surveys.*

*Percentage of women currently using modern contraceptive methods who discontinued by switching to another* 

**50**

**Table 3.**

**Figure 3.**

*method, DHS surveys.*

*Percentage of women currently using modern contraceptive methods who discontinued due to desire to become pregnant, DHS surveys.*


**Table 5.**

*Percentage of women currently using modern contraceptive methods who discontinued due to side effects, DHS surveys.*

#### **6. Factors associated with the use of modern contraception**

The current body of knowledge is replete with literature on the factors associated with the use of modern contraception. Systematically, these factors are grouped into two broad categories:

#### 1.Individual factors

2.Contextual factors

#### **6.1 Individual factors**

Education of the woman appeared as a strong and consistent predictor of contraceptive uptake. Across many studies, women with higher level of education reported current use of modern contraception compared to those with none or lower level [81–84]. Educated women are more likely to use modern contraception because it facilitates several pathways to use contraception. For instance, educated women are more likely to know where to access contraception and also more likely to be financially empowered to purchase if the need warrants. By giving her the financial and decisionmaking autonomy, education gives the woman the confidence to engage her spouse (husband) on discussing the need to use contraception for social, fertility and medical reasons. Age of the woman has also been found to play an important role in modern use of contraception. Younger women were found to be using less of contraception particularly if they had had no living children [79]. It is the desire of every woman to bear a child immediately after getting married most especially in high-fertility countries. After achieving the desired number of children, the use of contraception increases [85, 86]. Women who perceived their husband's disapproval of contraception are unlikely to use it partly due to cultural dominance of the husband as the sole decision-maker [72, 87]. Male partner involvement has been shown by numerous studies to positively increase use of contraception by women [88]. Also, positive male attitudes toward family planning have been reported to influence the use of contraception both from cross-sectional questionnaire and focus group discussion studies [89, 90]. Other individual-level characteristics reported to influence use of modern contraception include being employed [81, 84], religion [91–93] and spousal communication [72, 92].

#### **6.2 Contextual factors**

Broadly, the contextual factors considered here include socio-cultural, economic and health systems, specifically, place of residence, household economic status, social networks, accessible health facilities and/or health care workers providing contraception.

Women residing in urban areas have an advantage through both improved access to variety of contraception and being exposed to information channels that could positively influence utilization [92]. This urban advantage is also linked to average higher educational level of the women in urban areas as well as accessibility and being aware of facilities (both public and private) providing family planning services dotting the urban areas [71, 94, 95]. Household wealth level has also been reported to positively influence uptake of contraception. With higher household economic status, women are most likely to overcome cost-related barriers to the commodity and hidden cost of transportation and opportunity cost to obtain contraception [83]. Strong social networks among men that encourage and support use of modern contraception are a significant factor in increased use among the wives of these social networks [82, 96]. Other contextual factors known to positively increase contraceptive uptake include available and accessible facilities providing family planning services [70, 92, 97], visit by a health care worker or having a discussion with health care worker on contraception [98], cultural norms concerning fertility and contraception [92, 99, 100].

#### **7. Conclusion**

Understanding the factors beyond the individual and household characteristics that affect utilization and household characteristics that affect utilization of these

**53**

**Author details**

Alhaji A. Aliyu\* and Tukur Dahiru

provided the original work is properly cited.

Department of Community Medicine, Faculty of Clinical Sciences, College of

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Medical Sciences, Ahmadu Bello University, Zaria, Nigeria

\*Address all correspondence to: alhajimph@gmail.com

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

important maternal health services can assist in designing the strategies and developing policies and interventions toward improvement of service utilization across SSA. This will decrease the unacceptably high maternal mortality. The determinants of reproductive health and FP services in Africa are multi-sectional and thus will require multi-sectoral approach in addressing them. Socio-cultural, health, transportation, education, empowerment and other factors will need to be on board as part of sustainable long-term approach to improve access to services and utilization. Linking poor, rural women, improving service quality and access to ANC, delivery and PNC including FP services can go a long way in increasing utilization that could

*DOI: http://dx.doi.org/10.5772/intechopen.92138*

further improve health outcomes and achieve SDGs.

The authors declare no conflict of interest.

**Conflict of interest**

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

important maternal health services can assist in designing the strategies and developing policies and interventions toward improvement of service utilization across SSA. This will decrease the unacceptably high maternal mortality. The determinants of reproductive health and FP services in Africa are multi-sectional and thus will require multi-sectoral approach in addressing them. Socio-cultural, health, transportation, education, empowerment and other factors will need to be on board as part of sustainable long-term approach to improve access to services and utilization. Linking poor, rural women, improving service quality and access to ANC, delivery and PNC including FP services can go a long way in increasing utilization that could further improve health outcomes and achieve SDGs.

### **Conflict of interest**

*Family Planning and Reproductive Health*

Education of the woman appeared as a strong and consistent predictor of contraceptive uptake. Across many studies, women with higher level of education reported current use of modern contraception compared to those with none or lower level [81–84]. Educated women are more likely to use modern contraception because it facilitates several pathways to use contraception. For instance, educated women are more likely to know where to access contraception and also more likely to be financially empowered to purchase if the need warrants. By giving her the financial and decisionmaking autonomy, education gives the woman the confidence to engage her spouse (husband) on discussing the need to use contraception for social, fertility and medical reasons. Age of the woman has also been found to play an important role in modern use of contraception. Younger women were found to be using less of contraception particularly if they had had no living children [79]. It is the desire of every woman to bear a child immediately after getting married most especially in high-fertility countries. After achieving the desired number of children, the use of contraception increases [85, 86]. Women who perceived their husband's disapproval of contraception are unlikely to use it partly due to cultural dominance of the husband as the sole decision-maker [72, 87]. Male partner involvement has been shown by numerous studies to positively increase use of contraception by women [88]. Also, positive male attitudes toward family planning have been reported to influence the use of contraception both from cross-sectional questionnaire and focus group discussion studies [89, 90]. Other individual-level characteristics reported to influence use of modern contraception include being employed

Broadly, the contextual factors considered here include socio-cultural, economic

and health systems, specifically, place of residence, household economic status, social networks, accessible health facilities and/or health care workers providing

Women residing in urban areas have an advantage through both improved access to variety of contraception and being exposed to information channels that could positively influence utilization [92]. This urban advantage is also linked to average higher educational level of the women in urban areas as well as accessibility and being aware of facilities (both public and private) providing family planning services dotting the urban areas [71, 94, 95]. Household wealth level has also been reported to positively influence uptake of contraception. With higher household economic status, women are most likely to overcome cost-related barriers to the commodity and hidden cost of transportation and opportunity cost to obtain contraception [83]. Strong social networks among men that encourage and support use of modern contraception are a significant factor in increased use among the wives of these social networks [82, 96]. Other contextual factors known to positively increase contraceptive uptake include available and accessible facilities providing family planning services [70, 92, 97], visit by a health care worker or having a discussion with health care worker on contraception [98], cultural norms

Understanding the factors beyond the individual and household characteristics that affect utilization and household characteristics that affect utilization of these

[81, 84], religion [91–93] and spousal communication [72, 92].

concerning fertility and contraception [92, 99, 100].

**6.1 Individual factors**

**6.2 Contextual factors**

contraception.

**52**

**7. Conclusion**

The authors declare no conflict of interest.

#### **Author details**

Alhaji A. Aliyu\* and Tukur Dahiru Department of Community Medicine, Faculty of Clinical Sciences, College of Medical Sciences, Ahmadu Bello University, Zaria, Nigeria

\*Address all correspondence to: alhajimph@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2. Geneva: WHO; 2010. Available from: http://www.popline.org/ node/216706 [Accessed: 15 October 2019]

[2] WHO: Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva: World Health Organization; 2004

[3] Islam M. The safe motherhood interactive and beyond: (Editorials). Bulletin of the World Health Organization. 2007;**85**:10

[4] Pruel A, Toure A, Huguet D, Laurent Y. The quality of risk factor screening during antenatal consultation in Niger. Health Policy and Planning. 2000;**15**(1):11-16

[5] WHO. WHO Recommended Interventions for Improving Maternal and Newborn Health. Geneva: WHO; 2009

[6] Omo-Aghoja L. Sexual and reproductive health: Concepts and current status among Nigerians. African Journal of Medical and Health Sciences. 2013;**12**:103-113

[7] Horton R. Reviving reproductive health. Lancet. 2006;**368**(1549): 1595-1607

[8] WHO. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: WHO; 2016. Available from: http://www.who.int/ iristream/10665 [Accessed: 16 July 2018]

[9] Testa J, Ouedraogo C, Prual A, Bernish D, Kone B. Determinants of risk factors associated with severe maternal morbidity: Application during antenatal consultations. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 2002;**31**:44-50

[10] Ransjo-Arvidson AB, Chintu K, N'gandu N, Erikson B, Susu D, Christensson K, et al. Maternal and infant health problems after normal childbirth: A randomized controlled study in Zambia. Journal of Epidemiology and Community Health. 1998;**52**:385-391

[11] AbouZahr C, Berer M. When pregnancy is over: Preventing postpartum deaths and morbidity-safe motherhood initiatives: Critical issues. In: Berer M, Ravindran TKS, editors. Reproductive Health Matter. London: Great Britain-Spider Web; 1999

[12] Magadi MA, Zulu E, Brocherhoff M. The inequality of maternal health in urban sub-Saharan Africa in the 1990s. Population Studies. 2003;**57**:347-366

[13] WHO/UNICEF/UNFPA. Maternal mortality in 2000. Estimates developed by WHO, UNICEF, UNFPA. 2004

[14] Tawiah EO. Maternal health care in five sub-Saharan African countries. African Population Studies. 2011;**25**(1):1-25

[15] Tawiah EO. Determinants maternal health care in Ghana. Ghana Medical Journal. 1998;**32a**:917-925

[16] Magadi MA, Diamond I, Madise N, Smith P. Pathways of the determinants of unfavourable birth outcomes in Kenya. Journal of Biosocial Science. 2004;**36**:153-176

[17] Ram F, Singh A. Is antenatal care effective in improving maternal health in rural Uttar Pradesh? Evidence from a district level household survey. Journal of Biosocial Science. 2006;**38**:433-448

**55**

1968. p. 372

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

Regional Office for Europe (Health Evidence Network Report); 2005

[28] Damstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Lancet Neonatal Steering Team. Evidencedbased cost effective interventions: How many newborn babies can we save?

[29] Wang W, Alva S, Wang S, Fort A. Levels and Trends in the Use of Maternal Health Services in Developing Countries. ICF Macro: Calver ton, MD, USA; 2011

[27] Dansou J, Adekunle AO, Arowojolu AO. Factors associated with antenatal care services utilization patterns amongst reproductive age women in Benin Republic: An analysis of 2011-12 Benin Republic's DHS data. The Nigerian Postgraduate Medical

Journal. 2017;**24**:67-74

Lancet. 2005;**365**:977-978

[30] Mpembeni R, Kilewo J, Leshabari M, Siriel N, Massawe S, Jahn A, et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: Implications for achievement of MDG-5 targets. BMC Pregnancy and

Childbirth. 2007;**7**:29

2008;**85**(3):428-442

[31] Fotso JC, Even A, Oronje R. Provision and use of maternal health services among urban poor women in Kenya: What do we know and what can we do? Journal of Urban Health.

[32] Obago IT. The Role of Antenatal Care in Predicting Health Facility Delivery Among Women in Kenya: Further

Analysis of Data from the 2008-09 KDHS. DHS Working Papers No. 86. Calverton, Maryland, USA: ICF International; 2013

[33] Ochako R, Fotso JC, Ikamari L, Khasakhala A. Utilization of maternal health services among young women in Kenya: Insights from Kenya

demographic health survey 2003. BMC Pregnancy and Childbirth. 2011;**11**:1

*DOI: http://dx.doi.org/10.5772/intechopen.92138*

[18] Ikeako I, Onah HE, Iloabachie GC. Influence of formal education on the use of maternity services in Enugu Nigeria. Journal of Obstetrics and Gynaecology.

[19] Addai I. Determinants of use of maternal-child health services in rural Ghana. Journ of Biosocial Science.

[20] Nwakoby BN. Use of obstetric services in rural Nigeria. Journal of the Royal Society of Health.

[21] Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: Examining the scale of the problem and the importance of context. Bulletin of the World Health Organization.

[22] McCray M. An issue of culture: The effects of daily activities on parental care utilization patterns in rural south Africa. Social Science and Medicine.

2006;**1**:30-34

2000;**32**(1):1-15

1994;**114**:132-136

2007;**85**:812-819

2004;**59**:1843-1855

[23] Ayanore MA, Pavlova M,

Reproductive Health. 2016;**13**:5

[24] Leke RJI. Family Planning in Africa South of the Sahara. Available from: https://www.gfmer.ch/Books/ Reproductive\_Health2016:13.5

[25] Caldwell JC. Population policy: A survey of Commonwealth Africa. In: Caldwell JC, Okonjo C, editors. The Population of Tropical Africa. New York: Columbia University Press;

[26] Mario D, Basevi V, Spettoli D. What is the Effectiveness of Antenatal Care? (Supplement). Copenhagen: WHO

Groot W. Unmet reproductive health needs among women in some West African Countries: A systematic review of outcome measures and determinants. *Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

[18] Ikeako I, Onah HE, Iloabachie GC. Influence of formal education on the use of maternity services in Enugu Nigeria. Journal of Obstetrics and Gynaecology. 2006;**1**:30-34

[19] Addai I. Determinants of use of maternal-child health services in rural Ghana. Journ of Biosocial Science. 2000;**32**(1):1-15

[20] Nwakoby BN. Use of obstetric services in rural Nigeria. Journal of the Royal Society of Health. 1994;**114**:132-136

[21] Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: Examining the scale of the problem and the importance of context. Bulletin of the World Health Organization. 2007;**85**:812-819

[22] McCray M. An issue of culture: The effects of daily activities on parental care utilization patterns in rural south Africa. Social Science and Medicine. 2004;**59**:1843-1855

[23] Ayanore MA, Pavlova M, Groot W. Unmet reproductive health needs among women in some West African Countries: A systematic review of outcome measures and determinants. Reproductive Health. 2016;**13**:5

[24] Leke RJI. Family Planning in Africa South of the Sahara. Available from: https://www.gfmer.ch/Books/ Reproductive\_Health2016:13.5

[25] Caldwell JC. Population policy: A survey of Commonwealth Africa. In: Caldwell JC, Okonjo C, editors. The Population of Tropical Africa. New York: Columbia University Press; 1968. p. 372

[26] Mario D, Basevi V, Spettoli D. What is the Effectiveness of Antenatal Care? (Supplement). Copenhagen: WHO

Regional Office for Europe (Health Evidence Network Report); 2005

[27] Dansou J, Adekunle AO, Arowojolu AO. Factors associated with antenatal care services utilization patterns amongst reproductive age women in Benin Republic: An analysis of 2011-12 Benin Republic's DHS data. The Nigerian Postgraduate Medical Journal. 2017;**24**:67-74

[28] Damstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Lancet Neonatal Steering Team. Evidencedbased cost effective interventions: How many newborn babies can we save? Lancet. 2005;**365**:977-978

[29] Wang W, Alva S, Wang S, Fort A. Levels and Trends in the Use of Maternal Health Services in Developing Countries. ICF Macro: Calver ton, MD, USA; 2011

[30] Mpembeni R, Kilewo J, Leshabari M, Siriel N, Massawe S, Jahn A, et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: Implications for achievement of MDG-5 targets. BMC Pregnancy and Childbirth. 2007;**7**:29

[31] Fotso JC, Even A, Oronje R. Provision and use of maternal health services among urban poor women in Kenya: What do we know and what can we do? Journal of Urban Health. 2008;**85**(3):428-442

[32] Obago IT. The Role of Antenatal Care in Predicting Health Facility Delivery Among Women in Kenya: Further Analysis of Data from the 2008-09 KDHS. DHS Working Papers No. 86. Calverton, Maryland, USA: ICF International; 2013

[33] Ochako R, Fotso JC, Ikamari L, Khasakhala A. Utilization of maternal health services among young women in Kenya: Insights from Kenya demographic health survey 2003. BMC Pregnancy and Childbirth. 2011;**11**:1

**54**

*Family Planning and Reproductive Health*

[1] Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2. Geneva: WHO; 2010. Available antenatal consultations. Journal de Gynecologie, Obstetrique et Biologie de

la Reproduction. 2002;**31**:44-50

Chintu K, N'gandu N, Erikson B, Susu D, Christensson K, et al. Maternal and infant health problems after normal childbirth: A randomized controlled study in Zambia. Journal of Epidemiology and Community Health.

[11] AbouZahr C, Berer M. When pregnancy is over: Preventing

postpartum deaths and morbidity-safe motherhood initiatives: Critical issues. In: Berer M, Ravindran TKS, editors. Reproductive Health Matter. London: Great Britain-Spider Web; 1999

[12] Magadi MA, Zulu E, Brocherhoff M. The inequality of maternal health in urban sub-Saharan Africa in the 1990s. Population Studies. 2003;**57**:347-366

[13] WHO/UNICEF/UNFPA. Maternal mortality in 2000. Estimates developed by WHO, UNICEF, UNFPA. 2004

[15] Tawiah EO. Determinants maternal health care in Ghana. Ghana Medical

[16] Magadi MA, Diamond I, Madise N, Smith P. Pathways of the determinants of unfavourable birth outcomes in Kenya. Journal of Biosocial Science.

[17] Ram F, Singh A. Is antenatal care effective in improving maternal health in rural Uttar Pradesh? Evidence from a district level household survey. Journal of Biosocial Science. 2006;**38**:433-448

[14] Tawiah EO. Maternal health care in five sub-Saharan African countries. African Population Studies.

Journal. 1998;**32a**:917-925

2011;**25**(1):1-25

2004;**36**:153-176

[10] Ransjo-Arvidson AB,

1998;**52**:385-391

from: http://www.popline.org/ node/216706 [Accessed: 15 October

Organization; 2004

2000;**15**(1):11-16

2013;**12**:103-113

1595-1607

2009

[2] WHO: Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva: World Health

[3] Islam M. The safe motherhood interactive and beyond: (Editorials).

Bulletin of the World Health Organization. 2007;**85**:10

[4] Pruel A, Toure A, Huguet D, Laurent Y. The quality of risk factor screening during antenatal consultation in Niger. Health Policy and Planning.

[5] WHO. WHO Recommended Interventions for Improving Maternal and Newborn Health. Geneva: WHO;

[6] Omo-Aghoja L. Sexual and reproductive health: Concepts and current status among Nigerians. African Journal of Medical and Health Sciences.

[7] Horton R. Reviving reproductive health. Lancet. 2006;**368**(1549):

[8] WHO. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: WHO; 2016. Available from: http://www.who.int/ iristream/10665 [Accessed: 16 July 2018]

[9] Testa J, Ouedraogo C, Prual A, Bernish D, Kone B. Determinants of risk factors associated with severe maternal morbidity: Application during

2019]

**References**

[34] Babalola S, Fatusi A. Determinants of use of maternal health service in Nigeria-Looking beyond individual and household factors. BMC Pregnancy and Childbirth. 2009;**9**:43

[35] Simkhada B, Van Teijlingren ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. Journal of Advanced Nursing. 2007;**63**(3):244-260

[36] Kabir M, Iliyasu Z, Abubakar IS, Sani A. Determinants of utilization of antenatal care services in Kumbotso village, Northern Nigeria. Tropical Doctor. 2005;**35**:110-111

[37] Adamu YM, Salihu HM. Barriers to the use of antenatal and obstetric care services in rural Kano, Nigeria. Journal of Obstetrics and Gynaecology. 2002;**22**(6):600-603

[38] Mekonnen Y, Mekonnen A. Factors influencing the use of maternal health care services in Ethiopia. Journal of Health, Population and Nutrition. 2003;**21**(4):374-382

[39] Mathole T, Lindmark G, Majoko F, Ahlberg BM. A qualitative study of women's perspectives of antenatal care in rural area of Zimbabwe. Midwifery. 2004;**20**(2):122-132

[40] Ganle JK, Obang B, Segbetia AY, Mwinyuri V, Yeboah JY, Baatiema L. How intra familial decision-making affects women's access to, and use of maternal health care services in Ghana: A qualitative study. BMC Pregnancy and Childbirth. 2015;**15**:173

[41] WHO. The World Health Report 2005-Make Every Mother and Child Care Count. WHO; 2005

[42] WHO Skilled Attendant at Birth-2006 Updates. Geneva: WHO; 2006. Available from: http://www.who.int/ reproductive-health/global-monitoring/ skilled-attendant [Accessed: 28 October 2019]

[43] Abouzhar C. Maternal mortality overview. In: Murray CJ, Lopez AD, editors. Health Dimensions, Sex and Reproduction. Geneva: WHO; 1998. pp. 111-164

[44] Gabrysch S, Campbell OMR. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy and Childbirth. 2009;**9**:34

[45] Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet. 2005;**365**(9462):891-900

[46] National Population Commission (NPC) Nigeria and ICF. Nigeria Demographic and Rockville, Maryland USA: NPC and ICF; 2019

[47] Zimbabwe National Statistics Agency and ICF. Zimbabwe Demographic and Health Survey 2015 Final Report. Rockville, Maryland, USA: Zimbabwe National Statistics Agency (ZIMSTA) and ICF International. 2016

[48] Ghana Statistical Service (GSS), Ghana Health Service (GHS) and ICF. Ghana Maternal Health Service, 2017. Accra, Ghana: GSS, GHS and ICF; 2018

[49] Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) [Tanzania Mainland], Ministry of Health (MOH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) and ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Dares Salaam and Rockville, Maryland, USA: MOHCDGEC, MoH, NBS, OCGS and ICF; 2016

[50] Tarekegn SM, Lieberman LS, Gredraitis V. Determinants of maternal health service utilization in Ethiopia:

**57**

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

[59] Abuozahr C, Wardlaw T. Maternal mortality at the end of a decade: Signs of progress? Bulletin of the World Health

[60] WHO, editor. Postpartum Care of the Mothers and Newborn: A Practical Guide. Volth ed. Geneva: WHO; 1958.

[61] WHO. WHO Recommendations on Postnatal Care of Mothers and Newborn. Geneva: WHO; 2013

[62] Rwabufigiri BN, Mukamurigo J, Thomson DR, Hedt-Gautier BL, Semasaka JP. Factors associated with postnatal care utilization in Rwanda: A secondary analysis of 2010 Demographic and Health Survey Data. BMC Pregnancy and Childbirth.

[63] National Bureau of Statistics of Tanzania ICF International. Tanzania Demographic and Health Survey 2010. Available from: http://dhsprogram/ pubs/pdf/FR243 [Accessed: 25

[64] Aminah K. Factors Determining the Utilization of Postpartum Care Services in Uganda, Ugandan Demographic and

[65] Ahmed S, Creanga AA, Gilespie DG, Tsui AO. Economic status, education and empowerment: Implications for maternal health service utilization in developing countries. PLoS One.

[66] Demographic and Health Survey (DHS) Reports. Available from: https:// dhsprogram.com/publications/index.

[67] Khan S, Mishra V, Arnold F, Abderrahim N. Contraceptive Trends in Developing Countries. DHS Comparative Reports No. 16. Macro International Inc: Calverton, Maryland,

Health Survey (UDHS). 2006

Organization. 2001;**79**:561-568

WHO/RHT/MSM/983

2016;**16**:122

November 2019]

2010;**5**(6):e11190

ctm

USA; 2007

*DOI: http://dx.doi.org/10.5772/intechopen.92138*

Demographic and health Survey. BMC Pregnancy and Childbirth. 2014;**14**:161

[51] Aliyu AA. Family planning services in Africa: The successes and challenges. In: Amarin ZO, editor. Family Planning.

Analysis of the 2011 Ethiopian

London, UK: IntechOpen; 2018

[53] CSF (Ethiopia) and ICF

2004;**59**:1123

International; 2012

2018;**18**:175

2007;**65**:1666-1682

2011;**8**(1):1-12

[57] Gabysch S, Cox CS,

[58] Hodgkin D. Household characteristics affecting where

Economics. 1996;**5**(4):333-340

mothers deliver in rural Kenya. Health

Campbell OMR. The influence of distance and level of care on delivery place in rural Zambia: A study of linked national data in a geographic information system. PLoS Medicine.

[52] Burgard S. Race and pregnancyrelated care in Brazil and South Africa. Social Science and Medicine.

International: Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF

[54] Mwangi W, Gachuno O, Desai M, Obor D, Were V, Odhiambo F, et al. Uptake take of skill dance along the continuous of care in rural Western Kenya: Selected analysis from Global Health Initiative Survey 2012. Pregnancy and Childbirth.

[55] Shiferaw S, Spigt M, Godefroij M, Mel Kanu Y, Tekie M. Why do women prefer home births in Ethiopia? BMC Pregnancy and Child Birth. 2013;**13**:5

[56] Gaje AJ. Barriers to the utilization of maternal health care in rural Mali. Social Science and Medicine.

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

Analysis of the 2011 Ethiopian Demographic and health Survey. BMC Pregnancy and Childbirth. 2014;**14**:161

*Family Planning and Reproductive Health*

Childbirth. 2009;**9**:43

[34] Babalola S, Fatusi A. Determinants of use of maternal health service in Nigeria-Looking beyond individual and household factors. BMC Pregnancy and skilled-attendant [Accessed: 28 October

[43] Abouzhar C. Maternal mortality overview. In: Murray CJ, Lopez AD, editors. Health Dimensions, Sex and Reproduction. Geneva: WHO; 1998.

[44] Gabrysch S, Campbell OMR. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy and Childbirth.

[45] Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet. 2005;**365**(9462):891-900

[46] National Population Commission (NPC) Nigeria and ICF. Nigeria Demographic and Rockville, Maryland

[47] Zimbabwe National Statistics Agency and ICF. Zimbabwe

Demographic and Health Survey 2015 Final Report. Rockville, Maryland, USA: Zimbabwe National Statistics Agency (ZIMSTA) and ICF International. 2016

[48] Ghana Statistical Service (GSS), Ghana Health Service (GHS) and ICF. Ghana Maternal Health Service, 2017. Accra, Ghana: GSS, GHS and ICF;

[49] Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) [Tanzania Mainland], Ministry of Health (MOH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) and ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Dares Salaam and Rockville, Maryland, USA: MOHCDGEC, MoH,

NBS, OCGS and ICF; 2016

[50] Tarekegn SM, Lieberman LS, Gredraitis V. Determinants of maternal health service utilization in Ethiopia:

USA: NPC and ICF; 2019

2019]

pp. 111-164

2009;**9**:34

2018

[35] Simkhada B, Van Teijlingren ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. Journal of Advanced

[36] Kabir M, Iliyasu Z, Abubakar IS, Sani A. Determinants of utilization of antenatal care services in Kumbotso village, Northern Nigeria. Tropical

[37] Adamu YM, Salihu HM. Barriers to the use of antenatal and obstetric care services in rural Kano, Nigeria. Journal of Obstetrics and Gynaecology.

[38] Mekonnen Y, Mekonnen A. Factors influencing the use of maternal health care services in Ethiopia. Journal of Health, Population and Nutrition.

[39] Mathole T, Lindmark G, Majoko F, Ahlberg BM. A qualitative study of women's perspectives of antenatal care in rural area of Zimbabwe. Midwifery.

[40] Ganle JK, Obang B, Segbetia AY, Mwinyuri V, Yeboah JY, Baatiema L. How intra familial decision-making affects women's access to, and use of maternal health care services in Ghana: A qualitative study. BMC Pregnancy and

[41] WHO. The World Health Report 2005-Make Every Mother and Child

[42] WHO Skilled Attendant at Birth-2006 Updates. Geneva: WHO; 2006. Available from: http://www.who.int/ reproductive-health/global-monitoring/

Nursing. 2007;**63**(3):244-260

Doctor. 2005;**35**:110-111

2002;**22**(6):600-603

2003;**21**(4):374-382

2004;**20**(2):122-132

Childbirth. 2015;**15**:173

Care Count. WHO; 2005

**56**

[51] Aliyu AA. Family planning services in Africa: The successes and challenges. In: Amarin ZO, editor. Family Planning. London, UK: IntechOpen; 2018

[52] Burgard S. Race and pregnancyrelated care in Brazil and South Africa. Social Science and Medicine. 2004;**59**:1123

[53] CSF (Ethiopia) and ICF International: Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International; 2012

[54] Mwangi W, Gachuno O, Desai M, Obor D, Were V, Odhiambo F, et al. Uptake take of skill dance along the continuous of care in rural Western Kenya: Selected analysis from Global Health Initiative Survey 2012. Pregnancy and Childbirth. 2018;**18**:175

[55] Shiferaw S, Spigt M, Godefroij M, Mel Kanu Y, Tekie M. Why do women prefer home births in Ethiopia? BMC Pregnancy and Child Birth. 2013;**13**:5

[56] Gaje AJ. Barriers to the utilization of maternal health care in rural Mali. Social Science and Medicine. 2007;**65**:1666-1682

[57] Gabysch S, Cox CS, Campbell OMR. The influence of distance and level of care on delivery place in rural Zambia: A study of linked national data in a geographic information system. PLoS Medicine. 2011;**8**(1):1-12

[58] Hodgkin D. Household characteristics affecting where mothers deliver in rural Kenya. Health Economics. 1996;**5**(4):333-340

[59] Abuozahr C, Wardlaw T. Maternal mortality at the end of a decade: Signs of progress? Bulletin of the World Health Organization. 2001;**79**:561-568

[60] WHO, editor. Postpartum Care of the Mothers and Newborn: A Practical Guide. Volth ed. Geneva: WHO; 1958. WHO/RHT/MSM/983

[61] WHO. WHO Recommendations on Postnatal Care of Mothers and Newborn. Geneva: WHO; 2013

[62] Rwabufigiri BN, Mukamurigo J, Thomson DR, Hedt-Gautier BL, Semasaka JP. Factors associated with postnatal care utilization in Rwanda: A secondary analysis of 2010 Demographic and Health Survey Data. BMC Pregnancy and Childbirth. 2016;**16**:122

[63] National Bureau of Statistics of Tanzania ICF International. Tanzania Demographic and Health Survey 2010. Available from: http://dhsprogram/ pubs/pdf/FR243 [Accessed: 25 November 2019]

[64] Aminah K. Factors Determining the Utilization of Postpartum Care Services in Uganda, Ugandan Demographic and Health Survey (UDHS). 2006

[65] Ahmed S, Creanga AA, Gilespie DG, Tsui AO. Economic status, education and empowerment: Implications for maternal health service utilization in developing countries. PLoS One. 2010;**5**(6):e11190

[66] Demographic and Health Survey (DHS) Reports. Available from: https:// dhsprogram.com/publications/index. ctm

[67] Khan S, Mishra V, Arnold F, Abderrahim N. Contraceptive Trends in Developing Countries. DHS Comparative Reports No. 16. Macro International Inc: Calverton, Maryland, USA; 2007

[68] Gareme M. Family planning and fertility decline in Africa: From 1950- 2010. In: Amarin Z, editor. Family Planning. Rijeka: IntechOpen; 2018

[69] Abiodun OM, Balogun OR. Sexual activity and contraceptive use among young female students of tertiary educational institutions in Ilorin, Nigeria. Contraception. 2009;**79**(2):146-149

[70] Teye JK. Modern contraceptive use among women in the Asuogyaman district of Ghana: Is reliability more important than health concerns? African Journal of Reproductive Health. 2013;**17**(2):58-71

[71] Asekun-Olarinmoye E, Adebimbe W, Bamidele J, Odu O, Asekum-Olarinmoye I, Ojofeitimi E. Barriers to use of modern contraceptives among women in an inner city area of Oshogbo metropolis, Osun State, Nigeria. International Journal of Women's Health. 2013;**5**:647-655

[72] Nwachukwu I, Obasi OO. Use of modern birth control methods among rural communities in Imo State, Nigeria. African Journal of Reproductive Health. 2008;**12**(1):101-108

[73] Ugboaja JO. Contraceptive choices and practices among urban women in south eastern Nigeria. Nigerian Journal of Medicine. 2011;**20**(3):360-365

[74] Ikeme ACC, Ezegwui HU, Uzodimma AC. Knowledge, attitude and use of emergency contraception among female undergraduates in Eastern Nigeria. Journal of Obstetrics and Gynaecology. 2005;**25**(5):491-493

[75] Chipeta EK, Chimwaza W, Kalilani-Phiri L. Contraceptive knowledge, beliefs and attitudes in rural Malawi: Misinformation, misbeliefs and misconceptions. Malawi Medical Journal. 2010;**22**(2):38-41

[76] Haddad LB, Cwiak C, Jamieson JD, Feldacker C, Tweya H, Hosseinipour M, et al. Contraceptive adherence among HIV-infected women in Malawi: A randomized controlled trial of the copper intrauterine device and depot medroxyprogesterone acetate. Contraception. 2013;**88**(6):737-743

[77] Iklaki CU, Ekubua JE, Abasiattai A, Massey EA, Itam IH. Spousal communication in contraceptive decisions among antenatal patients in Calabar, south eastern Nigeria. Nigerian Journal of Medicine. 2005;**14**(4): 405-407

[78] Omideyi AK, Akinyemi AI, Aina OI, Adeyemi AB, Fadeyibi OA, Bamiwuye SO. Contraceptive practice, unwanted pregnancies and induced abortion in Southwest Nigeria. Global Public Health. 2011;**6**(Suppl 1):S52-S72

[79] Bulto G, Zewdie T, Beyen T. Demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos Town, North West Ethiopia. BMC Women's Health. 2014;**14**(1):46

[80] National Statistical Office (NSO) [Papua New Guinea] and ICP. Papua New Guinea Demographic and Health Survey 2016-18. Port Moresby, Papua New Guinea and Rockville, Maryland, USA: NSO and ICF; 2019

[81] Palamuleni ME. Socio-economic and demographic factors affecting contraceptive use in Malawi. African Journal of Reproductive Health. 2013;**17**(3):91-104

[82] Paz-Soldan VA. How family planning ideas are spread within social groups in rural Malawi. Studies in Family Planning. 2004;**35**(4):275-290

[83] Crissman HP, Adanu RM, Harlow SD. Women's sexual empowerment and contraceptive use

**59**

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual…*

[91] Doctor HV, Phillips JF,

[92] Audu BM, El-Nafaty AU, Bako AG, Melah GS, Mairiga AG, Kullima AA. Attitude of Nigerian women to contraceptive use by men. Journal of Obstetrics and Gynaecology.

[94] Polisi A, Grebrehanna E,

[93] Keele JJ, Forste R, Flake DF. Hearing native voices: Contraceptive use in Matenwe Village, East Africa. African Journal of Reproductive Health.

Tesfaye G, Asefa F. Modern contraceptive utilization among female ART attendees in health facility of Gimbie town, West Ethiopia. Reproductive Health.

[95] Prata N, Weidert K, Sreenivas A. Meeting the need: Youth and family planning in sub-Saharan Africa. Contraception. 2013;**88**(1):83-90

[96] Chimbiri AM. The condom is an 'intruder' in marriage: Evidence from rural Malawi. Social Science and Medicine. 2007;**64**(5):1102-1115

[97] Marrone G, Abdul-Rahman L, De Connick Z, Johansson A. Predictors of contraceptive use among female adolescents in Ghana. African Journal of Reproductive Health.

[98] Kabagenyi A, Jennings L, Reid A. Barriers to male involvement in contraceptive uptake and reproductive health services: A qualitative study of men and women's perceptions in two rural districts in Uganda. Reproductive

2014;**18**(1):102-109

Health. 2014;**11**:1-10

2009;**40**(2):113-122

2008;**28**(6):621-625

2005;**9**(1):32-41

2014;**11**(1):30

Sakeah E. The influence of changes in women's religious affiliation on contraceptive use and fertility among the Kassena-Nankana of northern Ghana. Studies in Family Planning.

*DOI: http://dx.doi.org/10.5772/intechopen.92138*

in Ghana. Studies in Family Planning.

[84] Ijadunola MY. Male involvement in family planning decision making in Ile-Ife, Osun State, Nigeria. African Journal of Reproductive Health.

[85] Avidime S, Aku-Akai L, Mohammed AZ, Adaji S, Shittu OO, Ejembi CL. Fertility intentions, contraceptive awareness and contraceptive use among women in three communities of Northern Nigeria. African Journal of Reproductive Health. 2010;**14**(3):65-70

2012;**43**(3):201-212

2010;**14**(4):43-50

[86] Peer N, Morojele N,

[87] Orji EO, Ojofeitimi EO, Olanrewaju BA. The role of men in family planning decision-making in rural and urban Nigeria. The European

Journal of Contraception & Reproductive Health Care.

[88] Ajah LO. Male partner involvement in female contraceptive choices in Nigeria. Journal of Obstetrics and Gynaecology: The Journal of the

Institute of Obstetrics and Gynaecology.

[89] Bukar M, Audu BM, Usman HA, El-Nafaty AU, Massa AA, Melah GS. Gender attitude to the empowerment of women: An independent right to contraceptive acceptance, choice and practice. Journal of Obstetrics and Gynaecology. 2013;**33**(2):180-183

[90] Izugbara C, Ibisomi L, Ezeh AC, Mandara M. Gendered interests and

communication in Islamic northern Nigeria. The Journal of Family Planning

and Reproductive Health Care.

poor spousal contraceptive

2010;**36**(4):219-224

2007;**12**(1):70-75

2015;**35**:628-631

London L. Factors associated with contraceptive use in a rural area in Western Cape Province. South African Medical Journal. 2013;**103**(6):406

*Reproductive Health and Family Planning Services in Africa: Looking beyond Individual… DOI: http://dx.doi.org/10.5772/intechopen.92138*

in Ghana. Studies in Family Planning. 2012;**43**(3):201-212

*Family Planning and Reproductive Health*

[68] Gareme M. Family planning and fertility decline in Africa: From 1950- 2010. In: Amarin Z, editor. Family Planning. Rijeka: IntechOpen; 2018

[76] Haddad LB, Cwiak C, Jamieson JD, Feldacker C, Tweya H, Hosseinipour M, et al. Contraceptive adherence among HIV-infected women in Malawi: A randomized controlled trial of the copper intrauterine device and depot medroxyprogesterone acetate. Contraception. 2013;**88**(6):737-743

[77] Iklaki CU, Ekubua JE, Abasiattai A,

Massey EA, Itam IH. Spousal communication in contraceptive decisions among antenatal patients in Calabar, south eastern Nigeria. Nigerian

Journal of Medicine. 2005;**14**(4):

[78] Omideyi AK, Akinyemi AI, Aina OI, Adeyemi AB, Fadeyibi OA, Bamiwuye SO. Contraceptive practice, unwanted pregnancies and induced abortion in Southwest Nigeria. Global Public Health. 2011;**6**(Suppl 1):S52-S72

[79] Bulto G, Zewdie T, Beyen T.

Demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos Town, North West Ethiopia. BMC Women's Health. 2014;**14**(1):46

[80] National Statistical Office (NSO) [Papua New Guinea] and ICP. Papua New Guinea Demographic and Health Survey 2016-18. Port Moresby, Papua New Guinea and Rockville, Maryland,

[81] Palamuleni ME. Socio-economic and demographic factors affecting contraceptive use in Malawi. African Journal of Reproductive Health.

[82] Paz-Soldan VA. How family planning ideas are spread within social groups in rural Malawi. Studies in Family Planning. 2004;**35**(4):275-290

[83] Crissman HP, Adanu RM, Harlow SD. Women's sexual

empowerment and contraceptive use

USA: NSO and ICF; 2019

2013;**17**(3):91-104

405-407

[69] Abiodun OM, Balogun OR. Sexual

[70] Teye JK. Modern contraceptive use among women in the Asuogyaman district of Ghana: Is reliability more important than health concerns? African Journal of Reproductive Health.

activity and contraceptive use among young female students of tertiary educational institutions in Ilorin, Nigeria. Contraception.

2009;**79**(2):146-149

2013;**17**(2):58-71

2008;**12**(1):101-108

[71] Asekun-Olarinmoye E, Adebimbe W, Bamidele J, Odu O, Asekum-Olarinmoye I, Ojofeitimi E. Barriers to use of modern contraceptives among women in an inner city area of Oshogbo metropolis, Osun State, Nigeria. International Journal of Women's Health. 2013;**5**:647-655

[72] Nwachukwu I, Obasi OO. Use of modern birth control methods among rural communities in Imo State, Nigeria. African Journal of Reproductive Health.

[73] Ugboaja JO. Contraceptive choices and practices among urban women in south eastern Nigeria. Nigerian Journal of Medicine. 2011;**20**(3):360-365

Uzodimma AC. Knowledge, attitude and use of emergency contraception among female undergraduates in Eastern Nigeria. Journal of Obstetrics and Gynaecology. 2005;**25**(5):491-493

knowledge, beliefs and attitudes in rural Malawi: Misinformation, misbeliefs and misconceptions. Malawi Medical

[74] Ikeme ACC, Ezegwui HU,

[75] Chipeta EK, Chimwaza W, Kalilani-Phiri L. Contraceptive

Journal. 2010;**22**(2):38-41

**58**

[84] Ijadunola MY. Male involvement in family planning decision making in Ile-Ife, Osun State, Nigeria. African Journal of Reproductive Health. 2010;**14**(4):43-50

[85] Avidime S, Aku-Akai L, Mohammed AZ, Adaji S, Shittu OO, Ejembi CL. Fertility intentions, contraceptive awareness and contraceptive use among women in three communities of Northern Nigeria. African Journal of Reproductive Health. 2010;**14**(3):65-70

[86] Peer N, Morojele N, London L. Factors associated with contraceptive use in a rural area in Western Cape Province. South African Medical Journal. 2013;**103**(6):406

[87] Orji EO, Ojofeitimi EO, Olanrewaju BA. The role of men in family planning decision-making in rural and urban Nigeria. The European Journal of Contraception & Reproductive Health Care. 2007;**12**(1):70-75

[88] Ajah LO. Male partner involvement in female contraceptive choices in Nigeria. Journal of Obstetrics and Gynaecology: The Journal of the Institute of Obstetrics and Gynaecology. 2015;**35**:628-631

[89] Bukar M, Audu BM, Usman HA, El-Nafaty AU, Massa AA, Melah GS. Gender attitude to the empowerment of women: An independent right to contraceptive acceptance, choice and practice. Journal of Obstetrics and Gynaecology. 2013;**33**(2):180-183

[90] Izugbara C, Ibisomi L, Ezeh AC, Mandara M. Gendered interests and poor spousal contraceptive communication in Islamic northern Nigeria. The Journal of Family Planning and Reproductive Health Care. 2010;**36**(4):219-224

[91] Doctor HV, Phillips JF, Sakeah E. The influence of changes in women's religious affiliation on contraceptive use and fertility among the Kassena-Nankana of northern Ghana. Studies in Family Planning. 2009;**40**(2):113-122

[92] Audu BM, El-Nafaty AU, Bako AG, Melah GS, Mairiga AG, Kullima AA. Attitude of Nigerian women to contraceptive use by men. Journal of Obstetrics and Gynaecology. 2008;**28**(6):621-625

[93] Keele JJ, Forste R, Flake DF. Hearing native voices: Contraceptive use in Matenwe Village, East Africa. African Journal of Reproductive Health. 2005;**9**(1):32-41

[94] Polisi A, Grebrehanna E, Tesfaye G, Asefa F. Modern contraceptive utilization among female ART attendees in health facility of Gimbie town, West Ethiopia. Reproductive Health. 2014;**11**(1):30

[95] Prata N, Weidert K, Sreenivas A. Meeting the need: Youth and family planning in sub-Saharan Africa. Contraception. 2013;**88**(1):83-90

[96] Chimbiri AM. The condom is an 'intruder' in marriage: Evidence from rural Malawi. Social Science and Medicine. 2007;**64**(5):1102-1115

[97] Marrone G, Abdul-Rahman L, De Connick Z, Johansson A. Predictors of contraceptive use among female adolescents in Ghana. African Journal of Reproductive Health. 2014;**18**(1):102-109

[98] Kabagenyi A, Jennings L, Reid A. Barriers to male involvement in contraceptive uptake and reproductive health services: A qualitative study of men and women's perceptions in two rural districts in Uganda. Reproductive Health. 2014;**11**:1-10

[99] Anguzu R, Tweheyo R, Sekandi JN, Zalwango V, Muhumuza C, Tusiima S, et al. Knowledge and attitudes towards use of long acting reversible contraceptives among women of reproductive age in Lubaga division, Kampala district, Uganda. BMC Research Notes. 2014;**7**:153

**Chapter 4**

*and Jorge Galán*

indigenous women, Ecuador

Congress carried out in Paris.

**61**

**1. Introduction**

**Abstract**

Planning Methods in Ecuador'

*Ana Parra, Vladimir Robles-Bykbaev, Blas Garzón*

**Keywords:** planning methods, indigenous peoples, Cañari population,

Health is a fundamental human right, SRH is a part of health, and this gives the reason for SRR to also be a fundamental human right [1]. The term "reproductive rights" was made public at the First International Conference on Women's Health carried out in Amsterdam, Holland, in 1984 [2], whereas the term "sexual rights" was introduced as a negotiation strategy at the International Conference on Population and Development (ICPD) in 1994, with the purpose of guaranteeing the inclusion of reproductive rights in the final version of the El Cairo Declaration and Action Program [2]. In 1997, the World Declaration of Sexual Rights was formulated at the World Congress of Sexology (Valencia-Spain). It was later ratified at the General Convention of the Sexology Association (WAS) during the XV Sexology

*Yaroslava Robles-Bykbaev, Nina Naula, Javier Cornejo-Reyes,*

Sexual and reproductive health (SRH) is a fundamental human right that implies knowledge and exercise of sexual and reproductive rights (SSR). Among the latter are access to knowledge and use of contraceptive methods; therefore, SSR should be experienced as a constant experience that allows women to achieve full satisfaction and security in their sexual and reproductive sphere through their subjectivity, their body, and their social and cultural life. Knowing about family planning allows having the desired number of children determining the interval between pregnancies and choosing the contraceptive method according to the social, cultural and psychological beliefs, needs and conditions of each woman. However, indigenous women from Canton Cañar (Ecuador) have less access and knowledge to contraceptive methods, mainly due to the influence of social, cultural, religious and economic factors, among others. The lack of information about family planning in indigenous populations of the South of Ecuador has motivated this study; through a medical-anthropological approach, it is intended to determine what is the preference regarding contraceptive methods in indigenous Cañari women in the context of the Cañari culture and what are their perceptions regarding such methods.

Indigenous People

s

[100] Ejembi CL, Dahiru T, Aliyu AA. Contextual Factors Influencing Modern Contraceptive Use in Nigeria. DHS Working Papers No. 120. Rockville, Maryland, USA: ICF International; 2015

#### **Chapter 4**

*Family Planning and Reproductive Health*

use of long acting reversible contraceptives among women of reproductive age in Lubaga division, Kampala district, Uganda. BMC Research Notes. 2014;**7**:153

[99] Anguzu R, Tweheyo R, Sekandi JN, Zalwango V, Muhumuza C, Tusiima S, et al. Knowledge and attitudes towards

[100] Ejembi CL, Dahiru T, Aliyu AA. Contextual Factors Influencing Modern Contraceptive Use in Nigeria. DHS Working Papers No. 120. Rockville, Maryland, USA: ICF International; 2015

**60**

### Planning Methods in Ecuador' s Indigenous People

*Yaroslava Robles-Bykbaev, Nina Naula, Javier Cornejo-Reyes, Ana Parra, Vladimir Robles-Bykbaev, Blas Garzón and Jorge Galán*

#### **Abstract**

Sexual and reproductive health (SRH) is a fundamental human right that implies knowledge and exercise of sexual and reproductive rights (SSR). Among the latter are access to knowledge and use of contraceptive methods; therefore, SSR should be experienced as a constant experience that allows women to achieve full satisfaction and security in their sexual and reproductive sphere through their subjectivity, their body, and their social and cultural life. Knowing about family planning allows having the desired number of children determining the interval between pregnancies and choosing the contraceptive method according to the social, cultural and psychological beliefs, needs and conditions of each woman. However, indigenous women from Canton Cañar (Ecuador) have less access and knowledge to contraceptive methods, mainly due to the influence of social, cultural, religious and economic factors, among others. The lack of information about family planning in indigenous populations of the South of Ecuador has motivated this study; through a medical-anthropological approach, it is intended to determine what is the preference regarding contraceptive methods in indigenous Cañari women in the context of the Cañari culture and what are their perceptions regarding such methods.

**Keywords:** planning methods, indigenous peoples, Cañari population, indigenous women, Ecuador

#### **1. Introduction**

Health is a fundamental human right, SRH is a part of health, and this gives the reason for SRR to also be a fundamental human right [1]. The term "reproductive rights" was made public at the First International Conference on Women's Health carried out in Amsterdam, Holland, in 1984 [2], whereas the term "sexual rights" was introduced as a negotiation strategy at the International Conference on Population and Development (ICPD) in 1994, with the purpose of guaranteeing the inclusion of reproductive rights in the final version of the El Cairo Declaration and Action Program [2]. In 1997, the World Declaration of Sexual Rights was formulated at the World Congress of Sexology (Valencia-Spain). It was later ratified at the General Convention of the Sexology Association (WAS) during the XV Sexology Congress carried out in Paris.

The Organización Mundial de la Salud (OMS) [3] declared that sexual health is a state of physical, mental and social welfare related to sexuality. It demands a positive and careful treatment of sexuality and sexual relations, as well as the possibility of having pleasant and safe experiences that are free from coercion, discrimination and violence. The OMS precept on sexual health is exclusive, biased and oriented toward the western paradigm, since it does not correspond to the local reality of the Original Peoples of Ecuador such as the Cañari, determined by bio-psycho-sociocultural factors and economics such as ethnicity (especially indigenous and mestizo), religion (Catholic, Christian, Evangelical and charismatic groups, among others), literacy, social class, level of education, work activity and profession, among others. The aforementioned factors determine the way and lifestyle of the indigenous women of Cañar, their perception of SRH and the cultural imagery through which social construction on the use of contraceptive methods takes place.

reproduced collectively through the intersubjective experiences [17] of the Cañari culture. In the case of the indigenous women of Cañar, modesty in relation to body management has its essence in the tendency to hide sexual values so as not to turn the body into an object of pleasure [18] without permission and theocratic recognition of religion, for example, Catholic, Christian and Evangelical, among others,

Body shame or embarrassment arises as a result of the body, since it occurs in relation to some aspect of the body or body management [19]; specifically, the female body continues to be a place of shame for women; it is associated with passions and uncontrolled appetites and with something dirty and polluting [20]. That is, it constitutes the social, biological and cultural site where the intersubjectivities of mature and older women, families, men and subjects of the indigenous Cañari society discipline it, and thus socially control the behavior of adolescent and young adult women, as well as single, divorced or separated women to prevent them from experiencing sexuality related to family planning. Since the female body that has not been sacralized through ecclesiastical marriage, and by the mere fact of

Currently, the society of the Cañari culture still exercises social and biological control in the body of the indigenous women of Cañar, that is why Cañari society can accept birth control for women, as a normative and socially accepted behavior, only if women are married. This phenomenon already took place in Quito, Ecuador, in 1970 [21], since the main group of attention for family planning was women who already had children, most of them married, which reaffirmed the exercise of sexuality only under the conjugal mandate. According to the Organización

Panamericana de la Salud (OPS) and the Comisión Económica para América Latina y el Caribe (CEPAL), in Ecuador, between 67% and 90% of indigenous youth reside mostly in rural areas, and they also have social exclusion, determined by schooling (4–6 years of study approved) [22]. Being a young indigenous woman and residing in a rural sector together with having an early active sexual life will become indica-

The start of an active sexual life of teenagers at an early age implies risks such as unwanted pregnancy, sexually transmitted infections, clandestine abortions and social segregation, among other problems. It is estimated that in Latin America 50% of young people under 17 are sexually active [22]. In fact, in Ecuador, teenagers' sexual relations start at the age of 15 [23, 24]. In the case of teenagers' fertility (15–19 years old), an alarming increase of 11% between 1999 and 2004 and

In most nonwestern countries, and especially in indigenous contexts, women reach the state of biological and social adulthood with marriage and motherhood at a stage in life that—according to western chronological criteria—could be categorized as adolescence. In this way, the right to marry is connected to biological maturity in traditional societies [22]. Despite the fact that in indigenous communities the acquired right to access family planning is instrumentalized and admitted by marriage, women do not have the same freedom to exercise their SRR, including

Teenage women, young adults and single mature adults who choose a family planning method are socially singled out. Well, sexuality is repressed, since sexual relations before marriage is seen as a lack of honor and a risk for women [26]. Therefore, the women's body is relate to something dirty and polluting, for that reason that mentioned body plays again a fundamental role as a social and biological space for socialization of the experience of cultural values. In other words, the passions and and uncontrolled appetites that those women can have must be social controlled by the Cañari culture. Even more so, if they are single indigenous women, they are socially stigmatized or singled out; in fact, according to the

tors of risk for SRH, exclusion, poverty and difficulty for living conditions.

between 2007 and 2012 [25] has been observed in Ecuador.

that of family planning.

**63**

through consecrated union in the church (ecclesiastical marriage).

being a female body, becomes an impure space.

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

The ways and lifestyles of Cañari women have a direct "relationship with the land and fertility, as well as with physical spaces considered feminine," since they are assigned for physical and social reproduction in the community [4]. This task of reproduction prevents access to free-form contraceptive methods if they are single [5] or adolescents (18 years), since they are frowned upon by the community and are stigmatized. Therefore, the religious and cultural precepts of the Cañaris communities are focused on control [6] regarding the exercise of their SRR.

Cañari indigenous adolescents and young adult women have greater difficulties in accessing knowledge and care in contraception due to the taboo issue that SRH represents, but also due to traditional paradigms on the role of sexual reproduction, since in indigenous communities of the Ecuador the idea that sexuality is reserved for reproduction still prevails, and the generational continuities crossed by the power relations of the gender system are reinforced [7–9]. Specifically, because the house is considered a sacred and immutable group of male ancestry that controls access and management of symbolic reproduction related to fertility [10], and subordinates the symbolic representation of women towards the Nature, therefore, is a generator of life and a naturally reproductive subject [11].

Within the value system of the Cañari culture, the generational hierarchy within the female gender plays a fundamental role, since respect from one generation to another forbids the dialog between mothers and daughters about the use of contraceptive methods, due to a generational role assigned to women according to their life cycle. Therefore, it is forbidden to talk about sexuality and birth control methods ("take care" in terms of the indigenous community of Cañar) among older adult women, and young adults and adolescents.

Not being able to talk freely between women of one generation (adolescents and young adults) and those of another generation (mature adults and older adults) may be related to modesty as an acetic value within the value system of the Cañari culture governed by the influence of religion. Indeed, modesty is related to a form of social control mainly for the censorship of what is related to sexuality, therefore chastity, and also for its erotic connotation [12–14]. In other words, modesty plays a role as a sobering element for the redirection of indigenous sexual behavior, since it allows values such as dignity and honor to be achieved [15].

Shyness as a social value allows to build and achieve a stereotype of biological and social woman; therefore, it is through the body of indigenous women that the experience of social control of modesty or embodiment<sup>1</sup> is manifested, so that this body is the existential basis so that said social control can be generated and

<sup>1</sup> It consists of living, with and through the human body, a set of emotions and sensations we experiment throughout our lives [16].

#### *Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

The Organización Mundial de la Salud (OMS) [3] declared that sexual health is a state of physical, mental and social welfare related to sexuality. It demands a positive and careful treatment of sexuality and sexual relations, as well as the possibility of having pleasant and safe experiences that are free from coercion, discrimination and violence. The OMS precept on sexual health is exclusive, biased and oriented toward the western paradigm, since it does not correspond to the local reality of the Original Peoples of Ecuador such as the Cañari, determined by bio-psycho-sociocultural factors and economics such as ethnicity (especially indigenous and mestizo), religion (Catholic, Christian, Evangelical and charismatic groups, among others), literacy, social class, level of education, work activity and profession, among others. The aforementioned factors determine the way and lifestyle of the indigenous women of Cañar, their perception of SRH and the cultural imagery through which social construction on the use of contraceptive methods takes place. The ways and lifestyles of Cañari women have a direct "relationship with the land and fertility, as well as with physical spaces considered feminine," since they are assigned for physical and social reproduction in the community [4]. This task of reproduction prevents access to free-form contraceptive methods if they are single [5] or adolescents (18 years), since they are frowned upon by the community and are stigmatized. Therefore, the religious and cultural precepts of the Cañaris com-

*Family Planning and Reproductive Health*

munities are focused on control [6] regarding the exercise of their SRR.

generator of life and a naturally reproductive subject [11].

allows values such as dignity and honor to be achieved [15].

adult women, and young adults and adolescents.

throughout our lives [16].

**62**

Cañari indigenous adolescents and young adult women have greater difficulties in accessing knowledge and care in contraception due to the taboo issue that SRH represents, but also due to traditional paradigms on the role of sexual reproduction, since in indigenous communities of the Ecuador the idea that sexuality is reserved for reproduction still prevails, and the generational continuities crossed by the power relations of the gender system are reinforced [7–9]. Specifically, because the house is considered a sacred and immutable group of male ancestry that controls access and management of symbolic reproduction related to fertility [10], and subordinates the symbolic representation of women towards the Nature, therefore, is a

Within the value system of the Cañari culture, the generational hierarchy within the female gender plays a fundamental role, since respect from one generation to another forbids the dialog between mothers and daughters about the use of contraceptive methods, due to a generational role assigned to women according to their life cycle. Therefore, it is forbidden to talk about sexuality and birth control

methods ("take care" in terms of the indigenous community of Cañar) among older

Not being able to talk freely between women of one generation (adolescents and young adults) and those of another generation (mature adults and older adults) may be related to modesty as an acetic value within the value system of the Cañari culture governed by the influence of religion. Indeed, modesty is related to a form of social control mainly for the censorship of what is related to sexuality, therefore chastity, and also for its erotic connotation [12–14]. In other words, modesty plays a role as a sobering element for the redirection of indigenous sexual behavior, since it

Shyness as a social value allows to build and achieve a stereotype of biological and social woman; therefore, it is through the body of indigenous women that the experience of social control of modesty or embodiment<sup>1</sup> is manifested, so that this

<sup>1</sup> It consists of living, with and through the human body, a set of emotions and sensations we experiment

body is the existential basis so that said social control can be generated and

reproduced collectively through the intersubjective experiences [17] of the Cañari culture. In the case of the indigenous women of Cañar, modesty in relation to body management has its essence in the tendency to hide sexual values so as not to turn the body into an object of pleasure [18] without permission and theocratic recognition of religion, for example, Catholic, Christian and Evangelical, among others, through consecrated union in the church (ecclesiastical marriage).

Body shame or embarrassment arises as a result of the body, since it occurs in relation to some aspect of the body or body management [19]; specifically, the female body continues to be a place of shame for women; it is associated with passions and uncontrolled appetites and with something dirty and polluting [20]. That is, it constitutes the social, biological and cultural site where the intersubjectivities of mature and older women, families, men and subjects of the indigenous Cañari society discipline it, and thus socially control the behavior of adolescent and young adult women, as well as single, divorced or separated women to prevent them from experiencing sexuality related to family planning. Since the female body that has not been sacralized through ecclesiastical marriage, and by the mere fact of being a female body, becomes an impure space.

Currently, the society of the Cañari culture still exercises social and biological control in the body of the indigenous women of Cañar, that is why Cañari society can accept birth control for women, as a normative and socially accepted behavior, only if women are married. This phenomenon already took place in Quito, Ecuador, in 1970 [21], since the main group of attention for family planning was women who already had children, most of them married, which reaffirmed the exercise of sexuality only under the conjugal mandate. According to the Organización Panamericana de la Salud (OPS) and the Comisión Económica para América Latina y el Caribe (CEPAL), in Ecuador, between 67% and 90% of indigenous youth reside mostly in rural areas, and they also have social exclusion, determined by schooling (4–6 years of study approved) [22]. Being a young indigenous woman and residing in a rural sector together with having an early active sexual life will become indicators of risk for SRH, exclusion, poverty and difficulty for living conditions.

The start of an active sexual life of teenagers at an early age implies risks such as unwanted pregnancy, sexually transmitted infections, clandestine abortions and social segregation, among other problems. It is estimated that in Latin America 50% of young people under 17 are sexually active [22]. In fact, in Ecuador, teenagers' sexual relations start at the age of 15 [23, 24]. In the case of teenagers' fertility (15–19 years old), an alarming increase of 11% between 1999 and 2004 and between 2007 and 2012 [25] has been observed in Ecuador.

In most nonwestern countries, and especially in indigenous contexts, women reach the state of biological and social adulthood with marriage and motherhood at a stage in life that—according to western chronological criteria—could be categorized as adolescence. In this way, the right to marry is connected to biological maturity in traditional societies [22]. Despite the fact that in indigenous communities the acquired right to access family planning is instrumentalized and admitted by marriage, women do not have the same freedom to exercise their SRR, including that of family planning.

Teenage women, young adults and single mature adults who choose a family planning method are socially singled out. Well, sexuality is repressed, since sexual relations before marriage is seen as a lack of honor and a risk for women [26]. Therefore, the women's body is relate to something dirty and polluting, for that reason that mentioned body plays again a fundamental role as a social and biological space for socialization of the experience of cultural values. In other words, the passions and and uncontrolled appetites that those women can have must be social controlled by the Cañari culture. Even more so, if they are single indigenous women, they are socially stigmatized or singled out; in fact, according to the

Ministerio de Salud Pública del Ecuador (MSP), this social phenomenon stands out, since single mothers are the target of aggression and contempt in the community; and girls are physically and psychologically punished and are often expelled from home and from the community [27].

in 2001, the global fertility rate was 4.6 in the indigenous population in the province of Cañar, while for 2015, according to (SENPLADES), the number of teenage pregnancies (15–19 years) in Cañar [37] reached 11% in the province of Cañar. With the exposed background about cultural phenomenology, which has allowed to partially understand how the perception of sexuality takes place and, as a part of it, how the indigenous women of Cañar manage family planning, our interest is to determine their preferences regarding contraceptive methods, consid-

ering the fact that there is scarce information about it. For this purpose, a descriptive-exploratory study was conducted (diagnosis phase) that focused on determining the perception indigenous women, aged 19–59, of the rural areas of Juncal and Ingapirca and the urban area of Cañar have about the use of and prefer-

This was a descriptive-exploratory study because information about family planning in the indigenous communities located to the South of Ecuador, such as Cañar, is scarce and insufficient, especially due to their biological position.

reason, it was decided to work with a quotient of Cronbach's alpha of 0.7.

researchers usually get data but people disapprove of this:

Intercultural de Juncal.

Spanish and Kichwa.

**65**

Data gathering was done by administering a previously validated survey through the Cronbach's alpha test (0.7). This survey was administered in the city of Cañar in 3 occasions during 3 months, considering the fact that SRH is a taboo and reaching a quotient of Cronbach's alpha higher than 0.7 was not possible. As previously stated, on the one hand, it is necessary to consider the difficulty of accessing a social construct about SRH within the system of values of this population. On the other hand, this is an exploratory study (diagnosis phase or baseline) and there is not enough information about this population's preferences regarding birth control methods, and due to the structure of their cultural system and cosmogony, access to information is restricted by the marked complexity that the cultural construct of sexuality represents. For this

Sampling was done randomly to 25 women who identified themselves as indigenous. It was checked that they had a level of elementary, high school and higher education. The surveys were applied in high social activity strategic zones in three parishes: Cañar (urban), Ingapirca and Juncal (rural). Additionally, accessing to the next parishes was easier (see **Table 1**), considering the fact that, in general, it is not easy to gather information in indigenous communities because local and/or foreign

• In the community of Yaculoma, which belongs to the parish of Juncal, surveys

were applied to indigenous women attending the Unidad Educativa

• At the cattle square and the clothes market of the urban parish of Cañar.

The majority of the Cañari indigenous women interviewed belong to the parishes of Ingapirca (10) and Cañar (8) (see **Table 1**) and they speak both languages:

The analysis of information was done by using "R" open software, version 1.1.456. A descriptive statistical analysis was done (measurements of central and dispersion tendency) because it was necessary to start with a diagnosis phase of the preference the indigenous women of the city of Cañar have regarding the use of contraceptives.

• At the community of Vendeleche belonging to the parish of Ingapirca.

ence for contraceptive methods.

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

**2. Methodology and design**

For their part, married indigenous women who have children can opt for family planning; in addition, society assigns the role of motherhood as a central component of their existence and socially grants them prestige and social recognition [27]. We will then say that the prevailing cultural system, the model of social control based on religious asceticism, the generational hierarchy in the female gender, patriarchal domination and belonging to the indigenous ethnic group in localities of Cañar influence access to knowledge and care in SRH and SSR, and therefore access to family planning methods.

According to OMS [3], it is calculated that, at world level, 214 million women of childbearing age in developing countries want to postpone or stop procreation, but they do not use any modern contraceptive method. However, in Ecuador, according to INEC [28, 29], the indigenous population has the lowest knowledge of contraceptive methods (34.7% of a total of 221.558). Regarding the prevalence of contraceptives and demand for satisfactory family planning [30], a more substantial dependence on traditional methods is observed in Ecuador in women aged 15 to 49. In the case of contraceptive methods, indigenous women prefer the use of rhythm or calendar (24.6%), ligature (23.6%), IUD/IUS (copper spiral "T") (19.1%), injection (16.4%), abstinence (6.7%), contraceptive pill (5.3%) and, finally, condom (3.9%). From their part, mestizo women prefer tubal ligation or female sterilization (35.9%), contraceptive pill (18.7%), rhythm (15%), IUD/IUS (14%), injection (9.5%), condom (4.2%) and abstinence (1.2%).

The rhythm method is currently not recommended or is proscribed as being ineffective [31]. Furthermore, the fact that indigenous women prefer such a contraceptive method is a trend that reflects less access to knowledge and family planning. The preference for tubal ligation and the preference for the rhythm method reveal the place that women occupy with regard to the subject of rights [32]; however, the strong religious influence reflects how women, indigenous people and their partners consider the use of contraceptive methods as a sin, and for their part, men consider that their partners can return to being adulterous [33].

#### **1.1 Some data about the province and city of Cañar**

In the province of Cañar (located in southern Ecuador), 15.2% of its population identifies itself as indigenous, while 76.7% identifies itself as mestizos [34]. It is a culturally representative province of Ecuador regarding customs, history and archeological remains. In the Cañar canton (located in the Cañar Province in the south of the country), there are 12 parishes: Cañar, Chontamarca, Chorocopte, Ducur, General Morales, Gualleturo, Honorato Vásquez, Ingapirca, Juncal, San Antonio, Ventura and Zhud.

According to the Municipio Intercultural del Cañar [35], this canton has around 58,185 inhabitants, and 40% of the population is indigenous, represented mainly by the Cañari ethnic group. The Cañari people speak Kichwa and Spanish. The identities of each indigenous people of the Cañari culture take place through the colonial present, but also with some influence from the pre-Inca past [36]. Furthermore, expressions, manifestations and their cultural value system are subject to resignifications due to processes of cultural syncretism.

In 2015, according to the Secretaría Nacional de Planificación y Desarrollo (SENPLADES) [37], the illiteracy rate for the indigenous population of the Cañar Province represented 42.78% and the poverty rate 95.2%. According to CEPAL [38], *Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

Ministerio de Salud Pública del Ecuador (MSP), this social phenomenon stands out, since single mothers are the target of aggression and contempt in the community; and girls are physically and psychologically punished and are often expelled from

For their part, married indigenous women who have children can opt for family planning; in addition, society assigns the role of motherhood as a central component of their existence and socially grants them prestige and social recognition [27]. We will then say that the prevailing cultural system, the model of social control based on religious asceticism, the generational hierarchy in the female gender, patriarchal domination and belonging to the indigenous ethnic group in localities of Cañar influence access to knowledge and care in SRH and SSR, and therefore access to

According to OMS [3], it is calculated that, at world level, 214 million women of childbearing age in developing countries want to postpone or stop procreation, but they do not use any modern contraceptive method. However, in Ecuador, according to INEC [28, 29], the indigenous population has the lowest knowledge of contraceptive methods (34.7% of a total of 221.558). Regarding the prevalence of contraceptives and demand for satisfactory family planning [30], a more substantial dependence on traditional methods is observed in Ecuador in women aged 15 to 49. In the case of contraceptive methods, indigenous women prefer the use of rhythm or calendar (24.6%), ligature (23.6%), IUD/IUS (copper spiral "T") (19.1%), injection (16.4%), abstinence (6.7%), contraceptive pill (5.3%) and, finally, condom (3.9%). From their part, mestizo women prefer tubal ligation or female sterilization (35.9%), contraceptive pill (18.7%), rhythm (15%), IUD/IUS (14%), injection

The rhythm method is currently not recommended or is proscribed as being ineffective [31]. Furthermore, the fact that indigenous women prefer such a contraceptive method is a trend that reflects less access to knowledge and family planning. The preference for tubal ligation and the preference for the rhythm method reveal the place that women occupy with regard to the subject of rights [32]; however, the strong religious influence reflects how women, indigenous people and their partners consider the use of contraceptive methods as a sin, and for their part, men consider that their partners can return to being adulterous [33].

In the province of Cañar (located in southern Ecuador), 15.2% of its population identifies itself as indigenous, while 76.7% identifies itself as mestizos [34]. It is a culturally representative province of Ecuador regarding customs, history and archeological remains. In the Cañar canton (located in the Cañar Province in the south of the country), there are 12 parishes: Cañar, Chontamarca, Chorocopte, Ducur, General Morales, Gualleturo, Honorato Vásquez, Ingapirca, Juncal, San

According to the Municipio Intercultural del Cañar [35], this canton has around 58,185 inhabitants, and 40% of the population is indigenous, represented mainly by the Cañari ethnic group. The Cañari people speak Kichwa and Spanish. The identities of each indigenous people of the Cañari culture take place through the colonial present, but also with some influence from the pre-Inca past [36]. Furthermore, expressions, manifestations and their cultural value system are subject to

In 2015, according to the Secretaría Nacional de Planificación y Desarrollo (SENPLADES) [37], the illiteracy rate for the indigenous population of the Cañar Province represented 42.78% and the poverty rate 95.2%. According to CEPAL [38],

home and from the community [27].

*Family Planning and Reproductive Health*

(9.5%), condom (4.2%) and abstinence (1.2%).

**1.1 Some data about the province and city of Cañar**

resignifications due to processes of cultural syncretism.

Antonio, Ventura and Zhud.

**64**

family planning methods.

in 2001, the global fertility rate was 4.6 in the indigenous population in the province of Cañar, while for 2015, according to (SENPLADES), the number of teenage pregnancies (15–19 years) in Cañar [37] reached 11% in the province of Cañar.

With the exposed background about cultural phenomenology, which has allowed to partially understand how the perception of sexuality takes place and, as a part of it, how the indigenous women of Cañar manage family planning, our interest is to determine their preferences regarding contraceptive methods, considering the fact that there is scarce information about it. For this purpose, a descriptive-exploratory study was conducted (diagnosis phase) that focused on determining the perception indigenous women, aged 19–59, of the rural areas of Juncal and Ingapirca and the urban area of Cañar have about the use of and preference for contraceptive methods.

#### **2. Methodology and design**

This was a descriptive-exploratory study because information about family planning in the indigenous communities located to the South of Ecuador, such as Cañar, is scarce and insufficient, especially due to their biological position.

Data gathering was done by administering a previously validated survey through the Cronbach's alpha test (0.7). This survey was administered in the city of Cañar in 3 occasions during 3 months, considering the fact that SRH is a taboo and reaching a quotient of Cronbach's alpha higher than 0.7 was not possible. As previously stated, on the one hand, it is necessary to consider the difficulty of accessing a social construct about SRH within the system of values of this population. On the other hand, this is an exploratory study (diagnosis phase or baseline) and there is not enough information about this population's preferences regarding birth control methods, and due to the structure of their cultural system and cosmogony, access to information is restricted by the marked complexity that the cultural construct of sexuality represents. For this reason, it was decided to work with a quotient of Cronbach's alpha of 0.7.

Sampling was done randomly to 25 women who identified themselves as indigenous. It was checked that they had a level of elementary, high school and higher education. The surveys were applied in high social activity strategic zones in three parishes: Cañar (urban), Ingapirca and Juncal (rural). Additionally, accessing to the next parishes was easier (see **Table 1**), considering the fact that, in general, it is not easy to gather information in indigenous communities because local and/or foreign researchers usually get data but people disapprove of this:


The majority of the Cañari indigenous women interviewed belong to the parishes of Ingapirca (10) and Cañar (8) (see **Table 1**) and they speak both languages: Spanish and Kichwa.

The analysis of information was done by using "R" open software, version 1.1.456. A descriptive statistical analysis was done (measurements of central and dispersion tendency) because it was necessary to start with a diagnosis phase of the preference the indigenous women of the city of Cañar have regarding the use of contraceptives.


3.What family planning method is the most widely used and which age group of

4.How many children do women who have generally had tubal ligation have, how old were they when they decided to have tubal ligation and what is their

5.What is the age to begin the use of contraceptives in Cañari indigenous

**3.1 How many children do Cañari indigenous women have?**

It is important to mention here that the results obtained showed that the women were engaged in the following activities: farmer (28%), housewife (40%), merchants (8%), public servant (8%), teacher (8%), physiotherapy assistant (4%) and student (4%). The 80% of housewife women respondents and the 100% of the farmer women respondents have elementary school education. The Cañari indigenous women respondents above mentioned belongs to the communities of Cañar (8), Chorocopte (4), Tambo (1), Gualleturo (1), 14 Honorato Vásquez (1) and the parish

Women having a higher number of children are those who have elementary school education, especially indigenous women between 49 and 59 years old (see **Table 2**), probably due to the fact that only 193.5 (estimated number in thousands) cases of sterilized women between 15 and 49 years old were registered in Ecuador until 1987 [39]. For this reason, women living in rural areas of Ecuador in the 1990s (30 years ago) did not know much about tubal ligation as a contraceptive method. Consequently, it was not a well-known birth control option; on the other hand, it

was fundamental to have large families so that children can contribute to

*The panel shows how indigenous women have been categorized according to their marital status, scholarity, current occupation and community. As Table 1 shows, most women are married and have elementary school*

*and higher education, are from the communities of Cebadas and Coriurco, and are farmers.*

women prefers this method?

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

level of education?

women, and why?

of Ingapirca (10) (see **Figure 1**).

**Figure 1.**

**67**

**Table 1.**

*The table shows the Cañaris parishes were the surveys have been applied to indigenous women.*

Surveys were applied to volunteer indigenous women of Cañar of any marital status, aged 19–59, with a level of elementary, high school or higher education. Volunteer participants signed the informed consent before participating in this study. Surveys were applied by a previously trained team of women, and one of the team collaborators was a Kichwa native speaker and supported the rest or the team to access the communities.

#### **3. Results**

It is worth mentioning that the results obtained should be considered taking into account several variables: age, marital status, years of study, the level of education and current occupation, and also, all respondents were indigenous and Catholic.

The age range of respondents was between 19 and 59 years. It was observed that the average pregnancy per woman was 3.08, and the pregnancy range was from 0 to 8 children, 2.72 being the average. Regarding the level of education of respondents, 15 women had elementary school education, 3 women had high school instruction and 7 had a higher education degree. In relation to their marital status, 22 women were married, 1 woman had free union relationship and 2 were single.

We asked some questions in order to understand what is the preference regarding contraceptive methods in Cañari indigenous women and what are their perceptions regarding such methods:


It is important to mention here that the results obtained showed that the women were engaged in the following activities: farmer (28%), housewife (40%), merchants (8%), public servant (8%), teacher (8%), physiotherapy assistant (4%) and student (4%). The 80% of housewife women respondents and the 100% of the farmer women respondents have elementary school education. The Cañari indigenous women respondents above mentioned belongs to the communities of Cañar (8), Chorocopte (4), Tambo (1), Gualleturo (1), 14 Honorato Vásquez (1) and the parish of Ingapirca (10) (see **Figure 1**).

#### **3.1 How many children do Cañari indigenous women have?**

Women having a higher number of children are those who have elementary school education, especially indigenous women between 49 and 59 years old (see **Table 2**), probably due to the fact that only 193.5 (estimated number in thousands) cases of sterilized women between 15 and 49 years old were registered in Ecuador until 1987 [39]. For this reason, women living in rural areas of Ecuador in the 1990s (30 years ago) did not know much about tubal ligation as a contraceptive method. Consequently, it was not a well-known birth control option; on the other hand, it was fundamental to have large families so that children can contribute to

#### **Figure 1.**

*The panel shows how indigenous women have been categorized according to their marital status, scholarity, current occupation and community. As Table 1 shows, most women are married and have elementary school and higher education, are from the communities of Cebadas and Coriurco, and are farmers.*

Surveys were applied to volunteer indigenous women of Cañar of any marital status, aged 19–59, with a level of elementary, high school or higher education. Volunteer participants signed the informed consent before participating in this study. Surveys were applied by a previously trained team of women, and one of the team collaborators was a Kichwa native speaker and supported the rest or the team

*The table shows the Cañaris parishes were the surveys have been applied to indigenous women.*

**25 25 100%**

**Parishes Communities Indigenous women Total %** Cañar Cañar 2 8 32 Cañaribamba 1 Coriurco 3 Quilloac 2 Chorocopte La Capilla 2 4 16 Tretón 2 El Tambo Coyoctor 1 1 4 Gualleturo Gasa 1 1 4 Honorato Vásquez Sigsihuayco 1 1 4 Ingapirca Cebadas 6 10 40 Chuguin Grande 1 Cochapamba 1 Masanqui 1 Sisid 1

It is worth mentioning that the results obtained should be considered taking into account several variables: age, marital status, years of study, the level of education and current occupation, and also, all respondents were indigenous and Catholic. The age range of respondents was between 19 and 59 years. It was observed that the average pregnancy per woman was 3.08, and the pregnancy range was from 0 to 8 children, 2.72 being the average. Regarding the level of education of respondents, 15 women had elementary school education, 3 women had high school instruction and 7 had a higher education degree. In relation to their marital status, 22 women

were married, 1 woman had free union relationship and 2 were single.

1.How many children do Cañari indigenous women have?

We asked some questions in order to understand what is the preference regarding contraceptive methods in Cañari indigenous women and what are their

2.What is the most widely identified contraceptive method by the indigenous women of Cañar, according to the community they are from, their level of

to access the communities.

*Family Planning and Reproductive Health*

perceptions regarding such methods:

education and age?

**66**

**3. Results**

**Table 1.**


#### **Table 2.**

*Number of children that indigenous women of Cañar have according to age group and education level.*

Tubal ligation, for its part, has been identified as an inexpensive method, which

15 3 7 25

**Contraceptive methods Elementary school High school Higher education Total** All 1 1 Hormonal injection 5 1 6 Various 1 2 1 4 Implant 1 1 IUD/IUS 1 1 Pill 1 3 4 Tubal ligation 6 6 None 1 1 2

**3.3 What family planning method is the most widely used and which age group**

The contraceptive methods the indigenous married women of the city of Cañar who were surveyed prefer are tubal ligation (36%), none (28%), injections (12%), implants (12%), contraceptive pill (8%) and rhythm method (4%). The community where contraceptives are most widely used is Cebadas (24%) (see **Table 4**). It must be considered that most respondents were married (22–25 years old; see **Table 1**). This is worth noticing because single women did not want to participate to avoid being identified and stigmatized and criticized by the people of the community, as it was stated in the theoretical section of this discussion. It is also necessary to highlight that all the respondents declared themselves to be Catholic and, as it was

*Notice that the indigenous women of Cañar know about hormonal injection and/or tubal ligation, as well as implants, as valid options to avoid teenage pregnancy, IUD/IUS as a method that allows them to work, and*

*hormonal injection and/or implants as methods that allow them to plan their pregnancies.*

**of Cañari indigenous women prefers this method?**

*Contraceptive methods identified by Cañari indigenous women.*

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

is easy to access, allows family planning and avoids teenage pregnancy. Cañari indigenous women also say that it is easy to access hormonal injections, which allow family planning and avoid teenage pregnancy. Regarding contraceptive pills, indigenous women know about the last two advantages indicated above. There is also the perception that not using a contraceptive method is inexpensive. Finally, pills and/or hormonal injections are considered to be inexpensive and comfortable

(see **Figure 3**).

**Figure 3.**

**69**

**Table 3.**

#### **Figure 2.**

*Number of children that Cañari indigenous women have according to level of education and civil status.*

agricultural and livestock tasks, especially in rural areas. Currently, there are still indigenous communities in Cañar, where women having a higher number of children, that is, between 5 and 8 children, are those from the rural parishes of Cebadas, Cochapamba, Coriurco and Gasa, and they have between 5 and 6 years of education (elementary school), while single women or women who have a free union relationship have 1 child and are from Chuguin Grande, Cebadas and La Capilla (see **Figure 2**).

#### **3.2 What is the most widely identified contraceptive method by the indigenous women of Cañar, according to the community they are from, their level of education level and age?**

The two most widely known contraceptive methods by the Cañari indigenous women between 19 and 59 years old are tubal ligation (24%) and hormonal injection (24%), followed by the contraceptive pill (16%) and no method (8%). It is important to say that Cebadas is the community that most identify contraceptive methods (24%) as: hormonal injection, implant and tubal ligation (see **Table 3**).

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*


#### **Table 3.**

*Contraceptive methods identified by Cañari indigenous women.*

Tubal ligation, for its part, has been identified as an inexpensive method, which is easy to access, allows family planning and avoids teenage pregnancy. Cañari indigenous women also say that it is easy to access hormonal injections, which allow family planning and avoid teenage pregnancy. Regarding contraceptive pills, indigenous women know about the last two advantages indicated above. There is also the perception that not using a contraceptive method is inexpensive. Finally, pills and/or hormonal injections are considered to be inexpensive and comfortable (see **Figure 3**).

#### **3.3 What family planning method is the most widely used and which age group of Cañari indigenous women prefers this method?**

The contraceptive methods the indigenous married women of the city of Cañar who were surveyed prefer are tubal ligation (36%), none (28%), injections (12%), implants (12%), contraceptive pill (8%) and rhythm method (4%). The community where contraceptives are most widely used is Cebadas (24%) (see **Table 4**). It must be considered that most respondents were married (22–25 years old; see **Table 1**). This is worth noticing because single women did not want to participate to avoid being identified and stigmatized and criticized by the people of the community, as it was stated in the theoretical section of this discussion. It is also necessary to highlight that all the respondents declared themselves to be Catholic and, as it was

#### **Figure 3.**

*Notice that the indigenous women of Cañar know about hormonal injection and/or tubal ligation, as well as implants, as valid options to avoid teenage pregnancy, IUD/IUS as a method that allows them to work, and hormonal injection and/or implants as methods that allow them to plan their pregnancies.*

agricultural and livestock tasks, especially in rural areas. Currently, there are still indigenous communities in Cañar, where women having a higher number of children, that is, between 5 and 8 children, are those from the rural parishes of Cebadas, Cochapamba, Coriurco and Gasa, and they have between 5 and 6 years of education (elementary school), while single women or women who have a free union relationship have 1 child and are from Chuguin Grande, Cebadas and

*Number of children that Cañari indigenous women have according to level of education and civil status.*

**3.2 What is the most widely identified contraceptive method by the indigenous women of Cañar, according to the community they are from, their level of**

The two most widely known contraceptive methods by the Cañari indigenous women between 19 and 59 years old are tubal ligation (24%) and hormonal injection (24%), followed by the contraceptive pill (16%) and no method (8%). It is important to say that Cebadas is the community that most identify contraceptive methods

(24%) as: hormonal injection, implant and tubal ligation (see **Table 3**).

La Capilla (see **Figure 2**).

**Age group**

**Table 2.**

**Figure 2.**

**68**

**Marital status**

*Family Planning and Reproductive Health*

**Higher education**

Single 1 (1.47%)

**Elementary school**

12 (16.76%) 54 (79.41%) 2 (2.94%) 68 (100.0%)

19–28 Free Union 1 (1.47%) 10 (14.71%) Married 2 (2.94%) 5 (7.35%) 1 (1.47%)

29–38 Married 3 (4.41%) 11 (16.80%) 14 (20.59%) 39–48 Married 5 (7.35%) 21 (30.88%) 26 (38.24%) 49–59 Married 2 (2.94%) 16 (23.53%) 18 (26.47%)

*Number of children that indigenous women of Cañar have according to age group and education level.*

**High school** **Number of children**

**education level and age?**


#### **Table 4.**

*Contraceptive methods used by Cañari indigenous women.*

stated before, they have a system of social control; therefore, women's sexuality is also controlled.

Accessing contraceptive methods is considered to be easy for most women who are married, have a free union relationship, or are single. However, married women represent most of the sample of the respondents (22). Notwithstanding, in this group, women from the parishes of Gasa, Quilloac and Sisid consider that accessing contraceptive methods is difficult or very difficult (see **Figure 4**).

Married women (with elementary school and higher education level) think that the community has to condemn the behavior of single women who use contraceptive methods, as well as they have the perception that this will turn out to be a shame for families. Finally, they consider that the partners of single women who start contraception criticize them. This perception phenomenon is reproduced by women who have a free union relationship. Single women preferred not to answer, which may be associated to the stigma we talked about in the introductory theoretical part of this discussion (see **Figure 5**).

The family planning methods that Cañari indigenous women prefers are: 17 tubal ligation (50%), followed by hormonal injection (16.6%), implant (16.6%), 18 and pill (16.6%), pill (11.1%), and rhythm method (5.55%).

Women between the ages of 39 and 48 have more frequently had tubal ligation (24%), but women between the ages of 29 and 38 (16%) show also this phenomena, while women between the ages of 49 and 59 represent 4%. Young adult women

(19–28 years old) usually choose methods like hormonal injection, implant and contraceptive pill (28%), probably because they are temporal long-term methods

*Prevalent use of contraceptive methods by Cañari indigenous women according to their level of education and*

*This figure shows Cañari indigenous communities' perception about single women's use of contraceptives.*

**Contraceptive methods Age Elementary High school Higher education Total** Hormonal injection 19–28 2 1 3 Implant 19–28 1 1 1 3 Pill 19–28 1 1

Rhythm method 29–38 1 1 Tubal ligation 29–38 1 2 3

None 19–28 1 1 2

39–48 1 1

39–48 4 1 5 49–59 1 1

29–38 1 1 2 49–59 2 1 3

those who have elementary school education (see **Table 5**).

About 28% of Cañari indigenous women do not use any contraceptive method, and this is probably caused by their low level of education, since women in all the age groups (19–28, 29–38, 39–48 and 49–59) that do not use any kind of contraceptive method have elementary or high school education. On the contrary, women who more widely use contraceptives, besides being young (19–28 years old), are

The social phenomenon of prevalence of use of contraceptive methods similarly corresponds to women who have elementary school education. On the other hand, in the case of young women who do not use any contraceptive method and have elementary and high school education, the phenomenon is also related to the number of children they have: the higher the level of education they have, the fewer the

and they still want to have children.

**Figure 5.**

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

**Table 5.**

*age.*

**71**

number of children they have.

#### *Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

#### **Figure 5.**

stated before, they have a system of social control; therefore, women's sexuality is

**Contraceptive methods Single Free union Married Total** Hormonal injection 3 3 Implant 1 1 1 3 Pill 2 2 Rhythm method 1 1 Tubal ligation 9 9 None 1 6 7

contraceptive methods is difficult or very difficult (see **Figure 4**).

and pill (16.6%), pill (11.1%), and rhythm method (5.55%).

*This figure shows Cañari indigenous women's access to contraceptive methods.*

ical part of this discussion (see **Figure 5**).

*Contraceptive methods used by Cañari indigenous women.*

*Family Planning and Reproductive Health*

Accessing contraceptive methods is considered to be easy for most women who are married, have a free union relationship, or are single. However, married women represent most of the sample of the respondents (22). Notwithstanding, in this group, women from the parishes of Gasa, Quilloac and Sisid consider that accessing

2 1 22 25

Married women (with elementary school and higher education level) think that the community has to condemn the behavior of single women who use contraceptive methods, as well as they have the perception that this will turn out to be a shame for families. Finally, they consider that the partners of single women who start contraception criticize them. This perception phenomenon is reproduced by women who have a free union relationship. Single women preferred not to answer, which may be associated to the stigma we talked about in the introductory theoret-

The family planning methods that Cañari indigenous women prefers are: 17 tubal ligation (50%), followed by hormonal injection (16.6%), implant (16.6%), 18

Women between the ages of 39 and 48 have more frequently had tubal ligation (24%), but women between the ages of 29 and 38 (16%) show also this phenomena, while women between the ages of 49 and 59 represent 4%. Young adult women

also controlled.

**Table 4.**

**Figure 4.**

**70**

*This figure shows Cañari indigenous communities' perception about single women's use of contraceptives.*


#### **Table 5.**

*Prevalent use of contraceptive methods by Cañari indigenous women according to their level of education and age.*

(19–28 years old) usually choose methods like hormonal injection, implant and contraceptive pill (28%), probably because they are temporal long-term methods and they still want to have children.

About 28% of Cañari indigenous women do not use any contraceptive method, and this is probably caused by their low level of education, since women in all the age groups (19–28, 29–38, 39–48 and 49–59) that do not use any kind of contraceptive method have elementary or high school education. On the contrary, women who more widely use contraceptives, besides being young (19–28 years old), are those who have elementary school education (see **Table 5**).

The social phenomenon of prevalence of use of contraceptive methods similarly corresponds to women who have elementary school education. On the other hand, in the case of young women who do not use any contraceptive method and have elementary and high school education, the phenomenon is also related to the number of children they have: the higher the level of education they have, the fewer the number of children they have.

#### **3.4 How many children do Cañari indigenous women who have generally had tubal ligation have, how old were they when they decided to have tubal ligation and what is their level of education?**

We can see that Cañari indigenous women who have a higher level of education have fewer number of children. Ligation as a method of family planning prevails in the indigenous women of Cañar who have between 5 and 6 children. However, having 8 children in the current era is not prevalent. That is why, only 1 woman had a ligation when having this number of children (see **Figure 6**).

Respondents perceive that both the women they interact with and other women of the community who have undergone tubal ligation consider it to be "very dangerous" (20% and 44.4%). However, other women in these two groups consider tubal ligation to be "very safe" when their close acquaintances have undergone tubal ligation (40%) and also when their close acquaintances have not undergone tubal ligation (33.3%). Similarly, some women consider tubal ligation to be dangerous for their health, harmful for their bodies and the cause of abdominal pain. Finally, they say it weakens their bodies (6.7%), and surveyed women believe that tubal ligation is a sin (6.7%) (see **Figure 7**).

**3.5 What is the age to begin the use of contraceptives in Cañari indigenous**

*Respondents with elementary school level education perceive that adolescents at age 17 can, and also should, begin the use of contraceptives because adolescents have biological maturity, adolescents show social maturity, the contraceptives avoid teenage pregnancies and they also allow to study. But respondents with higher education level mostly perceive that adolescents should begin the use of contraceptives at age 17 because of their biological maturity and because the contraceptives limit family size, let family planning, avoid teenage pregnancies and*

Cañari indigenous women's perceptions about reasons to begin the use of contraceptives at age 17 in adolescents (see **Figure 8**) is very concerning, because they are too young, and it shows that in this community sexual activity starts very early. This is very dangerous not only because it predisposes them to sexually transmitted infections (STIs), unwanted pregnancy and abortion, but also because their adoles-

Based on the results obtained, we can state that the number of children the indigenous women of Cañar have, as it is already known, is connected to their level of education. This research has proven that the higher the number of children these indigenous women have, the fewer the years of education they have (inversely

The two contraceptive methods that are most widely identified by the indigenous Cañari people between the ages of 19 and 59 are tubal ligation (24%) and hormonal injection (24%), followed by the contraceptive pill (16%), no known method (8%), and, finally, hormonal injection/implant (4%), hormonal injection/tubal ligation

Women having a higher number of children (5–8) are from the rural parishes of

Tubal ligation is definitely the preferred contraceptive method (see **Table 4**) by

(4%), implant (4%), IUD/IUS (4%) and all the rest (4%) (see **Table 3**).

Cebadas, Cochapamba, Coriurco and Gasa and have 5 or 6 years of education (elementary school), while single women or women who have a free union relationship have 1 child and come from Chuguin Grande, Cebadas and La Capilla

women aged 29–59 (50% of all the family planning methods), including both women having elementary school education (higher number of children) and high

school education (fewer number of children). This is defined by the social

**women, and why?**

**Figure 8.**

*allow to study.*

**4. Conclusions**

(see **Figure 2**).

**73**

proportional) (see **Table 5**).

cence is reduced, and their adulthood starts early.

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

**Figure 6.**

*Prevalent use of tubal ligation by Cañari indigenous women.*

**Figure 7.**

*The figure shows Cañari indigenous women's perception about tubal ligation when their close acquaintances have undergone tubal ligation.*

#### **Figure 8.**

**3.4 How many children do Cañari indigenous women who have generally had tubal ligation have, how old were they when they decided to have tubal**

We can see that Cañari indigenous women who have a higher level of education have fewer number of children. Ligation as a method of family planning prevails in the indigenous women of Cañar who have between 5 and 6 children. However, having 8 children in the current era is not prevalent. That is why, only 1 woman had

Respondents perceive that both the women they interact with and other women of the community who have undergone tubal ligation consider it to be "very dangerous" (20% and 44.4%). However, other women in these two groups consider tubal ligation to be "very safe" when their close acquaintances have undergone tubal ligation (40%) and also when their close acquaintances have not undergone tubal ligation (33.3%). Similarly, some women consider tubal ligation to be dangerous for their health, harmful for their bodies and the cause of abdominal pain. Finally, they say it weakens their bodies (6.7%), and surveyed women believe that

*The figure shows Cañari indigenous women's perception about tubal ligation when their close acquaintances*

**ligation and what is their level of education?**

*Family Planning and Reproductive Health*

tubal ligation is a sin (6.7%) (see **Figure 7**).

*Prevalent use of tubal ligation by Cañari indigenous women.*

**Figure 6.**

**Figure 7.**

**72**

*have undergone tubal ligation.*

a ligation when having this number of children (see **Figure 6**).

*Respondents with elementary school level education perceive that adolescents at age 17 can, and also should, begin the use of contraceptives because adolescents have biological maturity, adolescents show social maturity, the contraceptives avoid teenage pregnancies and they also allow to study. But respondents with higher education level mostly perceive that adolescents should begin the use of contraceptives at age 17 because of their biological maturity and because the contraceptives limit family size, let family planning, avoid teenage pregnancies and allow to study.*

#### **3.5 What is the age to begin the use of contraceptives in Cañari indigenous women, and why?**

Cañari indigenous women's perceptions about reasons to begin the use of contraceptives at age 17 in adolescents (see **Figure 8**) is very concerning, because they are too young, and it shows that in this community sexual activity starts very early. This is very dangerous not only because it predisposes them to sexually transmitted infections (STIs), unwanted pregnancy and abortion, but also because their adolescence is reduced, and their adulthood starts early.

#### **4. Conclusions**

Based on the results obtained, we can state that the number of children the indigenous women of Cañar have, as it is already known, is connected to their level of education. This research has proven that the higher the number of children these indigenous women have, the fewer the years of education they have (inversely proportional) (see **Table 5**).

The two contraceptive methods that are most widely identified by the indigenous Cañari people between the ages of 19 and 59 are tubal ligation (24%) and hormonal injection (24%), followed by the contraceptive pill (16%), no known method (8%), and, finally, hormonal injection/implant (4%), hormonal injection/tubal ligation (4%), implant (4%), IUD/IUS (4%) and all the rest (4%) (see **Table 3**).

Women having a higher number of children (5–8) are from the rural parishes of Cebadas, Cochapamba, Coriurco and Gasa and have 5 or 6 years of education (elementary school), while single women or women who have a free union relationship have 1 child and come from Chuguin Grande, Cebadas and La Capilla (see **Figure 2**).

Tubal ligation is definitely the preferred contraceptive method (see **Table 4**) by women aged 29–59 (50% of all the family planning methods), including both women having elementary school education (higher number of children) and high school education (fewer number of children). This is defined by the social

phenomenon of change of values within this population's cultural system, just as the respondents, during the survey, besides answering questions, confessed that they decided to use contraceptive methods considering the fact that they help to improve both their economy and their children's quality of life. Also, they think that tubal ligation offers several advantages: it is inexpensive and is easy to access, and it allows family planning and avoids teenage pregnancy (see **Figure 3**). However, young women (19–28 years old) choose other methods: hormonal injection, implant and contraceptive pill (28%), considering the fact that they are long-term temporal methods and probably still want to have children.

**Acknowledgements**

**Conflict of interest**

**Author details**

**75**

Vladimir Robles-Bykbaev<sup>2</sup>

Yaroslava Robles-Bykbaev1,2\*, Nina Naula2

The authors declare no conflict of interest.

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

Salesiana."

This project was partially funded by the "Catedra UNESCO UPS Cuenca-Ecuador, Grupo de Investigación en Inteligencia Artificial y Tecnologías de Asistencia (GIATA) CuencaEcuador" and also by "Universidad Politécnica

, Javier Cornejo-Reyes2,3, Ana Parra2

, Blas Garzón<sup>2</sup> and Jorge Galán<sup>2</sup>

1 Grupo de Investigación en Terapia Celular y Medicina Regenerativa (TCMR),

2 GI-IATa, Cátedra UNESCO Tecnologías de apoyo para la Inclusión Educativa,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

3 Instituto Superior Tecnológico del Azuay (ISTA), Cuenca, Ecuador

Departamento de Medicina, Universidade da Coruña, Spain

Universidad Politécnica Salesiana, Cuenca, Ecuador

\*Address all correspondence to: zrobles@ups.edu.ec

provided the original work is properly cited.

,

Besides, tubal ligation was perceived by the surveys as "very dangerous," "very safe," "dangerous for health," "harmful to the body," "causes abdominal pain" and "weakens the body."

It is important to highlight that 28% of Cañari indigenous women do not use any contraceptive method. They are the women who have elementary or high school education. Again, it corresponds to the inversely proportional relationship: the higher the level of education, the fewer the number of children. Choosing natural or traditional contraceptive methods is also connected to "sin," this being the reason that some women value this behavior so as not to break this cultural and religious standard.

In general, accessing contraceptive methods, according to the survey results, is very easy, considering the fact that the Cañari indigenous women who participated in the survey were married (22) (see **Figure 4**). Single women did not want to participate in the survey due to the fact that their marital status limits their answers because they are the target of criticism, as it was indicated in the introductory part of this discussion. For this reason, married women know that their communities condemn the behavior of single women who use contraceptive methods. They also believe that it is a shame for the families of those women, and they think the partners of single women who start using contraceptive methods speak ill of them (see **Figure 5**). The target of criticism that is embodied in single women who use contraceptive methods or participated in the survey is related to shyness or the female stereotype. That is, through the indigenous women's bodies, social control of shyness is manifested in such a way that it becomes the existential basis of shyness. The strong influence of the social control exercised by religion is another important factor. In this study, all the surveys show that these women are Catholic and, as it was stated in the introductory theoretical part of this discussion, the religious component is a system of social control and, consequently, also controls women's sexuality, which is expressed through their bodies.

We need to state that the Cañari culture is marked by a system of values where religion plays the role of socially controlling women's sexual behavior and embodies the stigma of accessing contraceptive methods through a woman's body. This is lived as a set of experiences that modifies these women's access to contraceptive methods and, consequently, to family planning. We can also say that the number of children women having a low level of education have is a factor that determines the occurrence of the previous phenomenon. The fact that some mature adult women undergo tubal ligation is another important factor that needs to be paid attention to. Before 1990 (1987), a record of tubal ligations of women between the ages of 15 and 49 in Ecuador shows the lack of knowledge of this contraceptive method in rural communities; consequently, it was not considered to be a birth control and/or family planning option.

Finally, we also state that there is very concerning the beginning of the contraceptives use in cañari indigenous adolescents (see **Figure 8**) because they start sexual activity very early, and predisposes them to sexually transmitted infections (STIs), unwanted pregnancy and abortion; but, also because their adolescence is reduced, and their adulthood starts before.

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

#### **Acknowledgements**

phenomenon of change of values within this population's cultural system, just as the respondents, during the survey, besides answering questions, confessed that they decided to use contraceptive methods considering the fact that they help to improve both their economy and their children's quality of life. Also, they think that tubal ligation offers several advantages: it is inexpensive and is easy to access, and it allows family planning and avoids teenage pregnancy (see **Figure 3**). However, young women (19–28 years old) choose other methods: hormonal injection, implant and contraceptive pill (28%), considering the fact that they are long-term temporal

Besides, tubal ligation was perceived by the surveys as "very dangerous," "very safe," "dangerous for health," "harmful to the body," "causes abdominal pain" and

It is important to highlight that 28% of Cañari indigenous women do not use any contraceptive method. They are the women who have elementary or high school education. Again, it corresponds to the inversely proportional relationship: the higher the level of education, the fewer the number of children. Choosing natural or traditional contraceptive methods is also connected to "sin," this being the reason that some women value this behavior so as not to break this cultural and religious standard. In general, accessing contraceptive methods, according to the survey results, is very easy, considering the fact that the Cañari indigenous women who participated in the survey were married (22) (see **Figure 4**). Single women did not want to participate in the survey due to the fact that their marital status limits their answers because they are the target of criticism, as it was indicated in the introductory part of this discussion. For this reason, married women know that their communities condemn the behavior of single women who use contraceptive methods. They also believe that it is a shame for the families of those women, and they think the partners of single women who start using contraceptive methods speak ill of them (see **Figure 5**). The target of criticism that is embodied in single women who use contraceptive methods or participated in the survey is related to shyness or the female stereotype. That is, through the indigenous women's bodies, social control of shyness is manifested in such a way that it becomes the existential basis of shyness. The strong influence of the social control exercised by religion is another important factor. In this study, all the surveys show that these women are Catholic and, as it was stated in the introductory theoretical part of this discussion, the religious component is a system of social control and, consequently, also controls women's

We need to state that the Cañari culture is marked by a system of values where religion plays the role of socially controlling women's sexual behavior and embodies the stigma of accessing contraceptive methods through a woman's body. This is lived as a set of experiences that modifies these women's access to contraceptive methods and, consequently, to family planning. We can also say that the number of children women having a low level of education have is a factor that determines the occurrence of the previous phenomenon. The fact that some mature adult women undergo tubal ligation is another important factor that needs to be paid attention to. Before 1990 (1987), a record of tubal ligations of women between the ages of 15 and 49 in Ecuador shows the lack of knowledge of this contraceptive method in rural communities; consequently, it was not considered to be a birth control and/or

Finally, we also state that there is very concerning the beginning of the contraceptives use in cañari indigenous adolescents (see **Figure 8**) because they start sexual activity very early, and predisposes them to sexually transmitted infections (STIs), unwanted pregnancy and abortion; but, also because their adolescence is

methods and probably still want to have children.

*Family Planning and Reproductive Health*

sexuality, which is expressed through their bodies.

family planning option.

**74**

reduced, and their adulthood starts before.

"weakens the body."

This project was partially funded by the "Catedra UNESCO UPS Cuenca-Ecuador, Grupo de Investigación en Inteligencia Artificial y Tecnologías de Asistencia (GIATA) CuencaEcuador" and also by "Universidad Politécnica Salesiana."

### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Yaroslava Robles-Bykbaev1,2\*, Nina Naula2 , Javier Cornejo-Reyes2,3, Ana Parra2 , Vladimir Robles-Bykbaev<sup>2</sup> , Blas Garzón<sup>2</sup> and Jorge Galán<sup>2</sup>

1 Grupo de Investigación en Terapia Celular y Medicina Regenerativa (TCMR), Departamento de Medicina, Universidade da Coruña, Spain

2 GI-IATa, Cátedra UNESCO Tecnologías de apoyo para la Inclusión Educativa, Universidad Politécnica Salesiana, Cuenca, Ecuador

3 Instituto Superior Tecnológico del Azuay (ISTA), Cuenca, Ecuador

\*Address all correspondence to: zrobles@ups.edu.ec

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Özcan M, Beritken Ergin A, Acar Z. Sexual and Reproductive Rights in Turkey: An Owerview. Cokaely, Turkey: Kocaeli Üniversitsi Sosyal Bilimler Dergisi. pp. 122-136

[2] Davis L. Reconocimiento jurídico de los derechos sexuales: Un análisis comparativo con los derechos reproductivos. Sur, Revista Internacional de Direitos Humanos. [online]. 2008;**5**(8):60-83. DOI: 10.1590/S1806-6445200800 0100004

[3] Organización Mundial de la Salud (OMS). Planificación familiar. [Internet]. 2019. Available from: https:// www.who.int/es

[4] Milagros A, Cordero L, Vuttone M. Salud de la mujer indígena: Intervenciones para reducir la muerte materna. Vol. 23. BID, Almería: Editorial Universidad de Almería; 2010

[5] Espinosa, S. Maternidad Indígena: Los derechos, los deseos, las costumbres, en S. Lerner, I. Szasz, Salud Reproductiva y Condiciones de Vida en México, México, D.F.: El Colegio de México. 2008. p. 169

[6] Internacional A. Políticas del cuerpo: manual general sobre la criminalización de la sexualidad y la reproducción. London: Amnesty International Ltd; 2018. p. 52

[7] Pedone C. Madres e Hijas, Rupturas y Continuidades en los Roles de Género en la Migración Ecuatoriana a España. In: Magliano M, Mallimaci A, editors. Las mujeres latinoamericanas y sus migraciones. Córdoba, Argentina: Eduvim; 2016

[8] Baeza P. Maternidad indígena en Colta: un espacio de encuentros y tensiones. Quito: Abya Yala; 2011. p. 17 [9] Weismantel M. Cholas y Pishtacos: Stories of Race and Sex in the Andes. Chicago, USA; University of Chicago Press; 2001. p. 76

Healing. California: Univesrity of California Press; 1997. pp. 8, 10

Simón Bolívar; 2007. p. 100

[18] Burgos J. La filosofía personalista de Karol Wojtyla. Madrid, Palabra (tesis de maestría). Quito: Universidad Andina

*Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

> [26] Larrea S. Diagnóstico de la situación de la promoción, oferta y demanda de la anticoncepción de emergencia en Loja, Guayas, Pichincha, Esmeraldas y Chimborazo. Quito: Fundación Desafío y Coordinadora Juvenil por la Equidad

> [27] Ministerio de Salud Pública del Ecuador (MSP). Situación de Salud de los y las jóvenes indígenas en Ecuador: VIH y Sida y Embarazo en Adolescentes Informe-Ecuador (Español). Quito:

[28] Instituto Nacional de Estadísticas y Censos (INEC). Comportamiento reproductivo de las mujeres

ecuatorianas. Quito: INEC; 2005. p. 30

[29] Instituto Nacional de Estadísticas y

ecuatorianas que conocen y usan los métodos anticonceptivos. Quito: INEC;

[30] Gómez R, Ewerling F, Serruya S, Silveira M, Sanhueza A, Moazzam A, et al. Contraceptive use in Latin

America and the Caribbean with a focus on long-acting reversible contraceptives:

Prevalence and inequalities in 23 countries. The Lancet. Global Health. 2019. DOI: 10.1016/S2214-109X(18)

[31] Peláez J. El uso de métodos

[32] Rostagnol S. El papel de l@s ginecólog@s en la construcción de los derechos sexuales. In: Uruguay K, Prieto M, editors. Estudios Sobre Sexualidades en América Latina. Quito:

[33] Terborgh A, Rosen J, Gálvez R, Terceros W, Bertrand J, Bull S. La planificación familiar entre las poblaciones indígenas de América

FLACSO; 2008. p. 225

anticonceptivos en la adolescencia. Rev Cubana Obstet Ginecol. 2016. ISSN:

Censos (INEC). Las mujeres

2006. p. 12

30481-9

0138-600X

de Género; 2010. p. 30

MSP; 2010. pp. 40, 51

[19] Dolezal L. The Body and Shame: Phenomenology, Feminism, and the Socially Shaped Body. London: Lexignton Books; 2015. p. 7

[20] Bouson B. Embodied Shame: Uncovering Female Shame in

Contemporary Women's Writings. Vol. 2. New York: Sunny Press; 2010. p. 3

[21] Agudelo J. La planificación familiar Discursos sobre la vida y la sexualidad en Ecuador desde mediados del siglo XX. Quito: Abya Yala; 2017. p. 101

[22] Organización Panamericana de la Salud (OPS) y la Comisión Económica para América Latina y el Caribe (CEPAL). Salud de la población joven indígena en América Latina: un

panorama general. Vol. 54. Santiago de Chile: Naciones Unidas; 2011. p. 42

[23] Organización Panamericana de la

reproductiva y VIH de los jóvenes y adolescentes indígenas en Bolivia, Ecuador, Guatemala, Nicaragua y Perú. Washington, D.C.: OPS; 2010. p. 61

[24] Ministerio de Salud Pública del Ecuador. Plan Nacional de Salud Sexual y Salud Reproductiva 2017–2021. Quito:

[25] Instituto Nacional de Estadísticas y Censos (INEC). MSP e INEC presentan resultados de Demografía y Salud Sexual y Reproductiva. [Internet]. 2014. Available from: https://www.ecuadore ncifras.gob.ec/msp-e-inec-presentan-re sultados-de-demografia-y-salud-sexua l-y-reproductiva/ [Accessed: 12

Salud (OPS). Salud sexual y

MSP; 2017. p. 34

December 2019]

**77**

[10] Da S, Women K. Gender and Power among Indigenous Peoples of Portuguese Timor. Anuário Antropológico. Brasília: UnB; 2017. pp. 183-205

[11] Cabezas P. Maternidad indígena en Colta: un espacio de encuentros y tensiones. Quito: Abya Yala; 2011. p. 23

[12] Arias M. Determinantes próximos de la fecundidad: Comportamiento reproductivo de las indígenas Chamibida de Antioquia, Colombia. Rio de Janeiro: Cad. Saúde Pública; 2005. pp. 1087-1109. DOI: 10.1590/ S0102-311X2005000400011

[13] Urrea F, Posso J. Feminidades, sexualidades y colores de piel: Mujeres negras, indígenas, blancas-mestizas y transgeneristas negras en el suroccidente colombiano. Cali: Programa Editorial Universidad del Valle; 2015

[14] Vázquez V, Flores A. ¿Quién cosecha lo sembrado?: Relaciones de género en un área natural protegida mexicana. México, D.F.: Plaza y Valdes; 2002

[15] Müllauer-Seichter W, Fernández M, Herrera S, Maynar A, Merino M, Vega-Centeno I, et al. Maneras de narrar espacios y tiempos: Ad fontes: Corrientes en Etnohistoria. Vol. 402. Madrid: Editorial Universitaria Ramón Areces; 2012. p. 131

[16] Lirola, M, Carrasco, M, Espinosa, J, Paterna, J. Investigaciones sobre el impacto de la imagen corporal. 2019. ISBN: 978-84-17261-57-3

[17] Csordas T. The Sacred Self: A Cultural Phenomenology of Charismatic *Planning Methods in Ecuador's Indigenous People DOI: http://dx.doi.org/10.5772/intechopen.92714*

Healing. California: Univesrity of California Press; 1997. pp. 8, 10

**References**

Dergisi. pp. 122-136

www.who.int/es

[1] Özcan M, Beritken Ergin A, Acar Z. Sexual and Reproductive Rights in Turkey: An Owerview. Cokaely, Turkey: Kocaeli Üniversitsi Sosyal Bilimler

*Family Planning and Reproductive Health*

[9] Weismantel M. Cholas y Pishtacos: Stories of Race and Sex in the Andes. Chicago, USA; University of Chicago

[10] Da S, Women K. Gender and Power

among Indigenous Peoples of Portuguese Timor. Anuário

Antropológico. Brasília: UnB; 2017.

[11] Cabezas P. Maternidad indígena en Colta: un espacio de encuentros y tensiones. Quito: Abya Yala; 2011. p. 23

[12] Arias M. Determinantes próximos de la fecundidad: Comportamiento reproductivo de las indígenas

Chamibida de Antioquia, Colombia. Rio de Janeiro: Cad. Saúde Pública; 2005.

[14] Vázquez V, Flores A. ¿Quién cosecha lo sembrado?: Relaciones de género en un área natural protegida mexicana. México,

[15] Müllauer-Seichter W, Fernández M, Herrera S, Maynar A, Merino M, Vega-Centeno I, et al. Maneras de narrar espacios y tiempos: Ad fontes: Corrientes en Etnohistoria. Vol. 402. Madrid: Editorial Universitaria Ramón

[16] Lirola, M, Carrasco, M, Espinosa, J, Paterna, J. Investigaciones sobre el impacto de la imagen corporal. 2019.

pp. 1087-1109. DOI: 10.1590/ S0102-311X2005000400011

Universidad del Valle; 2015

D.F.: Plaza y Valdes; 2002

Areces; 2012. p. 131

ISBN: 978-84-17261-57-3

[17] Csordas T. The Sacred Self: A Cultural Phenomenology of Charismatic

[13] Urrea F, Posso J. Feminidades, sexualidades y colores de piel: Mujeres negras, indígenas, blancas-mestizas y transgeneristas negras en el suroccidente colombiano. Cali: Programa Editorial

Press; 2001. p. 76

pp. 183-205

[2] Davis L. Reconocimiento jurídico de los derechos sexuales: Un análisis comparativo con los derechos reproductivos. Sur, Revista

Internacional de Direitos Humanos. [online]. 2008;**5**(8):60-83. DOI: 10.1590/S1806-6445200800 0100004

[3] Organización Mundial de la Salud (OMS). Planificación familiar.

[Internet]. 2019. Available from: https://

[4] Milagros A, Cordero L, Vuttone M.

Intervenciones para reducir la muerte materna. Vol. 23. BID, Almería: Editorial

[5] Espinosa, S. Maternidad Indígena:

costumbres, en S. Lerner, I. Szasz, Salud Reproductiva y Condiciones de Vida en México, México, D.F.: El Colegio de

[6] Internacional A. Políticas del cuerpo: manual general sobre la criminalización de la sexualidad y la reproducción. London: Amnesty International Ltd;

[7] Pedone C. Madres e Hijas, Rupturas y Continuidades en los Roles de Género en la Migración Ecuatoriana a España. In: Magliano M, Mallimaci A, editors. Las mujeres latinoamericanas y sus migraciones. Córdoba, Argentina:

[8] Baeza P. Maternidad indígena en Colta: un espacio de encuentros y tensiones. Quito: Abya Yala; 2011. p. 17

Salud de la mujer indígena:

Universidad de Almería; 2010

Los derechos, los deseos, las

México. 2008. p. 169

2018. p. 52

Eduvim; 2016

**76**

[18] Burgos J. La filosofía personalista de Karol Wojtyla. Madrid, Palabra (tesis de maestría). Quito: Universidad Andina Simón Bolívar; 2007. p. 100

[19] Dolezal L. The Body and Shame: Phenomenology, Feminism, and the Socially Shaped Body. London: Lexignton Books; 2015. p. 7

[20] Bouson B. Embodied Shame: Uncovering Female Shame in Contemporary Women's Writings. Vol. 2. New York: Sunny Press; 2010. p. 3

[21] Agudelo J. La planificación familiar Discursos sobre la vida y la sexualidad en Ecuador desde mediados del siglo XX. Quito: Abya Yala; 2017. p. 101

[22] Organización Panamericana de la Salud (OPS) y la Comisión Económica para América Latina y el Caribe (CEPAL). Salud de la población joven indígena en América Latina: un panorama general. Vol. 54. Santiago de Chile: Naciones Unidas; 2011. p. 42

[23] Organización Panamericana de la Salud (OPS). Salud sexual y reproductiva y VIH de los jóvenes y adolescentes indígenas en Bolivia, Ecuador, Guatemala, Nicaragua y Perú. Washington, D.C.: OPS; 2010. p. 61

[24] Ministerio de Salud Pública del Ecuador. Plan Nacional de Salud Sexual y Salud Reproductiva 2017–2021. Quito: MSP; 2017. p. 34

[25] Instituto Nacional de Estadísticas y Censos (INEC). MSP e INEC presentan resultados de Demografía y Salud Sexual y Reproductiva. [Internet]. 2014. Available from: https://www.ecuadore ncifras.gob.ec/msp-e-inec-presentan-re sultados-de-demografia-y-salud-sexua l-y-reproductiva/ [Accessed: 12 December 2019]

[26] Larrea S. Diagnóstico de la situación de la promoción, oferta y demanda de la anticoncepción de emergencia en Loja, Guayas, Pichincha, Esmeraldas y Chimborazo. Quito: Fundación Desafío y Coordinadora Juvenil por la Equidad de Género; 2010. p. 30

[27] Ministerio de Salud Pública del Ecuador (MSP). Situación de Salud de los y las jóvenes indígenas en Ecuador: VIH y Sida y Embarazo en Adolescentes Informe-Ecuador (Español). Quito: MSP; 2010. pp. 40, 51

[28] Instituto Nacional de Estadísticas y Censos (INEC). Comportamiento reproductivo de las mujeres ecuatorianas. Quito: INEC; 2005. p. 30

[29] Instituto Nacional de Estadísticas y Censos (INEC). Las mujeres ecuatorianas que conocen y usan los métodos anticonceptivos. Quito: INEC; 2006. p. 12

[30] Gómez R, Ewerling F, Serruya S, Silveira M, Sanhueza A, Moazzam A, et al. Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: Prevalence and inequalities in 23 countries. The Lancet. Global Health. 2019. DOI: 10.1016/S2214-109X(18) 30481-9

[31] Peláez J. El uso de métodos anticonceptivos en la adolescencia. Rev Cubana Obstet Ginecol. 2016. ISSN: 0138-600X

[32] Rostagnol S. El papel de l@s ginecólog@s en la construcción de los derechos sexuales. In: Uruguay K, Prieto M, editors. Estudios Sobre Sexualidades en América Latina. Quito: FLACSO; 2008. p. 225

[33] Terborgh A, Rosen J, Gálvez R, Terceros W, Bertrand J, Bull S. La planificación familiar entre las poblaciones indígenas de América

Latina. Perspectivas Internacionales en Planificación Familiar. 1996;**4**(11):10

[34] Instituto Nacional de Estadísticas y Censos (INEC). Resultados del Censo 2010 de Población y Vivienda en el Ecuador: fascículo provincial del Cañar [Internet]. 2010. Available from: https://www.ecuadorencifras.gob.ec/ wp-content/descargas/Manu-lateral/ Resultados-provinciales/canar.pdf

[35] Municipio Intercultural del Cañar. Población [Internet]. 2019. Available from: https://www.canar.gob.ec/gadca nar/index.php/2013-05-20-16-30-14/ 2013-05-20-16-39-52

[36] Burgos H. La Identidad del Pueblo Cañari: de-construcción de una nación étnica. Quito: Abya Yala; 2003. pp. 33-37

[37] Secretaría Nacional de Planificación y Desarrollo (SENPLADES). Agenda Zonal, ZONA 6-Austro: Provicncias de Azuay, Cañar, y Morona Santiago. 2013–2017. Quito: SENPLADES; 2015. pp. 27, 40, 57

[38] Comisión Económica para América Latina y el Caribe (CEPAL). Población indígena y afroecuatoriana en Ecuador: Diagnóstico sociodemográfico a partir del censo de 2001. Santiago de Chile: Naciones Unidas; 2005. p. 28

[39] Organización Mundial de la Salud Ginebra (OMS). Guía para la Prestación de Servicios. Ginegra: OMS; 1993. p. 6

**79**

Section 4

Multiple Gestation

Section 4

## Multiple Gestation

Latina. Perspectivas Internacionales en Planificación Familiar. 1996;**4**(11):10

*Family Planning and Reproductive Health*

[34] Instituto Nacional de Estadísticas y Censos (INEC). Resultados del Censo 2010 de Población y Vivienda en el Ecuador: fascículo provincial del Cañar [Internet]. 2010. Available from: https://www.ecuadorencifras.gob.ec/ wp-content/descargas/Manu-lateral/ Resultados-provinciales/canar.pdf

[35] Municipio Intercultural del Cañar. Población [Internet]. 2019. Available from: https://www.canar.gob.ec/gadca nar/index.php/2013-05-20-16-30-14/

[36] Burgos H. La Identidad del Pueblo Cañari: de-construcción de una nación étnica. Quito: Abya Yala; 2003. pp. 33-37

[37] Secretaría Nacional de Planificación y Desarrollo (SENPLADES). Agenda Zonal, ZONA 6-Austro: Provicncias de Azuay, Cañar, y Morona Santiago. 2013–2017. Quito: SENPLADES; 2015.

[38] Comisión Económica para América Latina y el Caribe (CEPAL). Población indígena y afroecuatoriana en Ecuador: Diagnóstico sociodemográfico a partir del censo de 2001. Santiago de Chile:

[39] Organización Mundial de la Salud Ginebra (OMS). Guía para la Prestación de Servicios. Ginegra: OMS; 1993. p. 6

Naciones Unidas; 2005. p. 28

2013-05-20-16-39-52

pp. 27, 40, 57

**78**

**81**

gestation [4].

**Chapter 5**

*Ilkan Kayar*

**1. Introduction**

**Abstract**

Multifetal Gestations

In recent years, multiple pregnancy rates have increased significantly. Twin pregnancy rate increased by 76% between 1980 and 2009, from 18.9 to 33.3 in 1000 births. Triplets and high-order multiple pregnancies have increased by 400% in the 1980s and 1990s. Two main reasons of this increase in the incidence of multiple pregnancies are: (1) maternal age at the time of conception, shifting to advanced ages where multiple pregnancies are more common and (2) a more common use of assisted reproductive techniques. The main problem in multiple pregnancies is spontaneous preterm delivery and associated neonatal morbidity and mortality. Although numerous attempts have been made to prolong the gestation period and improve outcomes, none of them have been effective. In this article, the complications encountered in multiple pregnancies will be summarized and evidence-based

Multiple pregnancy rates have increased significantly in recent years. The twin pregnancy rate increased from 18.9 to 33.3 per 1,000 births between 1980 and 2009, increasing by 76% [1]. Multiple pregnancies with triplets and higher numbers increased by 400% in the 1980s and 1990s [2]. There are two main reasons for this increase in the incidence of multiple pregnancies: (1) Maternal age at the time of conception is shifting to advanced ages with multiple pregnancies and (2) a more

The main problem encountered in multiple pregnancies is spontaneous preterm labor and associated neonatal morbidity and mortality. Although several attempts have been made to prolong the duration of these pregnancies and improve outcomes, none of them have been effective. In this chapter, the complications encountered in multiple pregnancies will be summarized and evidence-based approaches

Due to complications caused by preterm labor, stillbirth rate in multiple pregnancies is five times higher, and neonatal mortality rate is seven times higher than other pregnancies. A woman with a multiple pregnancy is 6 times more likely to have a preterm delivery and 13 times more likely to give birth before 32 weeks of

approaches that can be used in their management will be reported.

**Keywords:** twins, triplets, monozygotic, dizygotic

common use of assisted reproductive techniques [3].

that can be applied in their management will be reported.

**2. Fetal and neonatal morbidity and mortality**

## **Chapter 5** Multifetal Gestations

*Ilkan Kayar*

### **Abstract**

In recent years, multiple pregnancy rates have increased significantly. Twin pregnancy rate increased by 76% between 1980 and 2009, from 18.9 to 33.3 in 1000 births. Triplets and high-order multiple pregnancies have increased by 400% in the 1980s and 1990s. Two main reasons of this increase in the incidence of multiple pregnancies are: (1) maternal age at the time of conception, shifting to advanced ages where multiple pregnancies are more common and (2) a more common use of assisted reproductive techniques. The main problem in multiple pregnancies is spontaneous preterm delivery and associated neonatal morbidity and mortality. Although numerous attempts have been made to prolong the gestation period and improve outcomes, none of them have been effective. In this article, the complications encountered in multiple pregnancies will be summarized and evidence-based approaches that can be used in their management will be reported.

**Keywords:** twins, triplets, monozygotic, dizygotic

#### **1. Introduction**

Multiple pregnancy rates have increased significantly in recent years. The twin pregnancy rate increased from 18.9 to 33.3 per 1,000 births between 1980 and 2009, increasing by 76% [1]. Multiple pregnancies with triplets and higher numbers increased by 400% in the 1980s and 1990s [2]. There are two main reasons for this increase in the incidence of multiple pregnancies: (1) Maternal age at the time of conception is shifting to advanced ages with multiple pregnancies and (2) a more common use of assisted reproductive techniques [3].

The main problem encountered in multiple pregnancies is spontaneous preterm labor and associated neonatal morbidity and mortality. Although several attempts have been made to prolong the duration of these pregnancies and improve outcomes, none of them have been effective. In this chapter, the complications encountered in multiple pregnancies will be summarized and evidence-based approaches that can be applied in their management will be reported.

#### **2. Fetal and neonatal morbidity and mortality**

Due to complications caused by preterm labor, stillbirth rate in multiple pregnancies is five times higher, and neonatal mortality rate is seven times higher than other pregnancies. A woman with a multiple pregnancy is 6 times more likely to have a preterm delivery and 13 times more likely to give birth before 32 weeks of gestation [4].

In multiple pregnancies, short- and long-term morbidity has also increased. Severe intraventricular hemorrhage and periventricular leukomalacia are two times more common in twins born before 32 weeks of gestation than in single babies born in the same week [5], and this explains the increased rate of cerebral palsy in multiple pregnancies [6].

In multiple pregnancies, still due to the prematurity, health expenses in both antenatal and neonatal periods are higher [7]. The spending made for preterm babies in the year after birth reaches 10 times the spending for full-term babies [8].

#### **3. Chorionicity**

Ultrasound is the reliable method to detect multiple pregnancies [9]. Ultrasound shows the number of fetuses, gestational week, chorionicity, and amnionicity. It is very important to detect chorionicity which is best assessed by ultrasound in the first or early second trimester.

Fetal and neonatal mortality and morbidities such as congenital anomaly, prematurity, and intrauterine growth restriction are much more common in monochorionic twins than in dichorionic twins [10, 11]. This also applies to high number of multiple pregnancies; completely monochorionic or monochorionic twin pairs have a higher risk of developing complications compared to trichoricionic triplet pregnancy [12, 13]. Thus, chorionicity should be determined in the late stages of the first trimester or early second trimester for the management of multiple pregnancies and consultancy.

#### **4. Maternal morbidity and mortality**

Medical complications such as hyperemesis, gestational diabetes, hypertension, anemia, bleeding, cesarean section, and postpartum depression are more common in women with multiple pregnancies [14–20]. These complications are managed as in singleton pregnancies.

The incidence of hypertensive complications is proportional to the number of fetuses, with 6.5% in singleton pregnancies, 12.7% in twins, and 20% in triplets [21].

In one study, it was found that the risk of developing mild or severe preeclampsia in pregnancies achieved by assisted reproductive techniques was 2.1 times higher than other pregnancies with the same maternal age and parity [22].

Preeclampsia occurs both more frequently (relative risk 2.6) and earlier in twin pregnancies. This results in a higher probability of developing complications such as birth before 35 weeks of gestation (34.5% in twins vs. 6.3% in singles) and ablation of the placenta (4.7% in twins vs. 0.7% in singles) [16]. While preeclampsia is more common in patients with higher-order gestations, it is atypical [23]. If hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome) occur before term, the patient's referral to the third line will be better for both the mother and the fetus [24].

The incidence of multiple pregnancy increases with age, regardless of assisted reproductive techniques. While the multiple pregnancy rate in women aged under 20 is 16.3 per 1000 live births, this rate is 71.1 per 1000 live births in women over 40 [2]. Regardless of the number of fetuses, obstetric complications such as gestational hypertension, gestational diabetes, and ablation placenta are more common in older women.

**83**

*Multifetal Gestations*

fully known.

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

**5. Effect of assisted reproductive techniques**

in twins, and 1.3% in higher-order gestations [25].

**6. Embryo reduction and selective feticide**

30% in pregnancies continuing as triplets [27].

cies without pregnancy loss [30, 31].

**7.1 How to determine chorionicity?**

**7. Questions and suggestions about clinic**

chorionicity was correctly determined in 95% of cases.

genicity as the placenta and pregnancy is dichorionic [33].

In the past years, the proliferation of assisted reproductive techniques has led to a serious increase in multiple pregnancy rates [1]. In recent years, there was a decrease in higher-order gestation rates with the limitation of the number of embryos transferred in vitro fertilization (IVF) and the proliferation of embryo reduction. The techniques that cause the most increase in the number of multiple pregnancies are IVF and controlled ovarian hyperstimulation with gonadotropins. According to the most recent data obtained in 2010, 26% of IVF pregnancies result

Embryo reduction causes a decrease in the risk of spontaneous preterm labor and other obstetric complications with decreased fetal number. In a Cochrane review, it was reported that the pregnancy loss, antenatal complication, preterm birth, low birth weight, and cesarean and neonatal death rates in pregnant women undergoing triplet-to-twin reduction were much lower than in those continuing as triplets and were close to the rates seen in spontaneous twins [26]. Embryo reduction in higher-order gestations also reduces the risk of preeclampsia. In one study, the preeclampsia incidence was 17% in pregnancies with reduction to twins and

In embryo reduction, the decision of which fetus or fetuses will be treated is determined according to chorionicity and easy accessibility. When one of the monochorionic twin pair is reduced, it is recommended that both monochorionic pair be reduced, since the harmful effects on the other twin are not

Selective feticide is the reduction of abnormal fetus in a multiple pregnancy. The

risk of this procedure is higher compared to embryo reduction, since it is performed at a later gestational week (18th–22nd week instead of 10–12th week) [28]. In higher-order gestations, unwanted loss of healthy fetuses is higher than twins (11.2% vs. 2.4%) [29]. It was observed that gestation period was longer in pregnan-

Since fetal risks depend on chorionicity, chorionicity should be determined as early as possible. The ideal period for the determination of chorionicity is late first or early second trimester. In a series, the sensitivity, specificity, and positive and negative predictive values of ultrasound in determining chorionicity before 14 weeks of gestation were 89.8%, 99.5%, 97.8%, and 97.5%, respectively [32], and

The pregnancy is dichorionic if the ultrasound shows two separate placentas or the gender of fetuses are different. In the case of a single placenta, the most important ultrasound finding used to determine chorionicity is the "twin peak" finding, also known as "lambda" or "delta" sign. This finding shows that there is a triangular shaped protrusion on the chorionic surface of the placenta having the same echo*Family Planning and Reproductive Health*

multiple pregnancies [6].

first or early second trimester.

cies and consultancy.

in singleton pregnancies.

**4. Maternal morbidity and mortality**

babies [8].

**3. Chorionicity**

In multiple pregnancies, short- and long-term morbidity has also increased. Severe intraventricular hemorrhage and periventricular leukomalacia are two times more common in twins born before 32 weeks of gestation than in single babies born in the same week [5], and this explains the increased rate of cerebral palsy in

In multiple pregnancies, still due to the prematurity, health expenses in both antenatal and neonatal periods are higher [7]. The spending made for preterm babies in the year after birth reaches 10 times the spending for full-term

Ultrasound is the reliable method to detect multiple pregnancies [9]. Ultrasound shows the number of fetuses, gestational week, chorionicity, and amnionicity. It is very important to detect chorionicity which is best assessed by ultrasound in the

Medical complications such as hyperemesis, gestational diabetes, hypertension, anemia, bleeding, cesarean section, and postpartum depression are more common in women with multiple pregnancies [14–20]. These complications are managed as

The incidence of hypertensive complications is proportional to the number of fetuses, with 6.5% in singleton pregnancies, 12.7% in twins, and 20% in triplets [21]. In one study, it was found that the risk of developing mild or severe preeclampsia in pregnancies achieved by assisted reproductive techniques was 2.1 times higher

Preeclampsia occurs both more frequently (relative risk 2.6) and earlier in twin pregnancies. This results in a higher probability of developing complications such as birth before 35 weeks of gestation (34.5% in twins vs. 6.3% in singles) and ablation of the placenta (4.7% in twins vs. 0.7% in singles) [16]. While preeclampsia is more common in patients with higher-order gestations, it is atypical [23]. If hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome) occur before term, the patient's referral to the third line will be better for both the mother and

The incidence of multiple pregnancy increases with age, regardless of assisted reproductive techniques. While the multiple pregnancy rate in women aged under 20 is 16.3 per 1000 live births, this rate is 71.1 per 1000 live births in women over 40 [2]. Regardless of the number of fetuses, obstetric complications such as gestational hypertension, gestational diabetes, and ablation placenta are more common in

than other pregnancies with the same maternal age and parity [22].

Fetal and neonatal mortality and morbidities such as congenital anomaly, prematurity, and intrauterine growth restriction are much more common in monochorionic twins than in dichorionic twins [10, 11]. This also applies to high number of multiple pregnancies; completely monochorionic or monochorionic twin pairs have a higher risk of developing complications compared to trichoricionic triplet pregnancy [12, 13]. Thus, chorionicity should be determined in the late stages of the first trimester or early second trimester for the management of multiple pregnan-

**82**

the fetus [24].

older women.

#### **5. Effect of assisted reproductive techniques**

In the past years, the proliferation of assisted reproductive techniques has led to a serious increase in multiple pregnancy rates [1]. In recent years, there was a decrease in higher-order gestation rates with the limitation of the number of embryos transferred in vitro fertilization (IVF) and the proliferation of embryo reduction. The techniques that cause the most increase in the number of multiple pregnancies are IVF and controlled ovarian hyperstimulation with gonadotropins. According to the most recent data obtained in 2010, 26% of IVF pregnancies result in twins, and 1.3% in higher-order gestations [25].

#### **6. Embryo reduction and selective feticide**

Embryo reduction causes a decrease in the risk of spontaneous preterm labor and other obstetric complications with decreased fetal number. In a Cochrane review, it was reported that the pregnancy loss, antenatal complication, preterm birth, low birth weight, and cesarean and neonatal death rates in pregnant women undergoing triplet-to-twin reduction were much lower than in those continuing as triplets and were close to the rates seen in spontaneous twins [26]. Embryo reduction in higher-order gestations also reduces the risk of preeclampsia. In one study, the preeclampsia incidence was 17% in pregnancies with reduction to twins and 30% in pregnancies continuing as triplets [27].

In embryo reduction, the decision of which fetus or fetuses will be treated is determined according to chorionicity and easy accessibility. When one of the monochorionic twin pair is reduced, it is recommended that both monochorionic pair be reduced, since the harmful effects on the other twin are not fully known.

Selective feticide is the reduction of abnormal fetus in a multiple pregnancy. The risk of this procedure is higher compared to embryo reduction, since it is performed at a later gestational week (18th–22nd week instead of 10–12th week) [28]. In higher-order gestations, unwanted loss of healthy fetuses is higher than twins (11.2% vs. 2.4%) [29]. It was observed that gestation period was longer in pregnancies without pregnancy loss [30, 31].

#### **7. Questions and suggestions about clinic**

#### **7.1 How to determine chorionicity?**

Since fetal risks depend on chorionicity, chorionicity should be determined as early as possible. The ideal period for the determination of chorionicity is late first or early second trimester. In a series, the sensitivity, specificity, and positive and negative predictive values of ultrasound in determining chorionicity before 14 weeks of gestation were 89.8%, 99.5%, 97.8%, and 97.5%, respectively [32], and chorionicity was correctly determined in 95% of cases.

The pregnancy is dichorionic if the ultrasound shows two separate placentas or the gender of fetuses are different. In the case of a single placenta, the most important ultrasound finding used to determine chorionicity is the "twin peak" finding, also known as "lambda" or "delta" sign. This finding shows that there is a triangular shaped protrusion on the chorionic surface of the placenta having the same echogenicity as the placenta and pregnancy is dichorionic [33].

#### **7.2 Is there a test to predict spontaneous preterm labor in multiple pregnancies?**

In order to determine the risk of spontaneous preterm labor in asymptomatic pregnant women, many screening methods such as measuring cervical canal length with transvaginal ultrasound, examination of the cervix, fetal fibronectin screening, and home uterus monitoring have been tried. These screening methods are not recommended in asymptomatic women because there is no intervention that can prevent preterm labor in multiple pregnancies that are found to be at high risk for preterm labor [34].

In symptomatic pregnant women, the positive predictive value of fetal fibronectin test alone or short cervical length is low and should not be used for the management of acute symptoms [35]. Although observational studies have shown that fetal fibronectin or cervical canal length precludes the use of unnecessary treatment in singleton pregnancies with preterm labor symptoms, these data have not been proven by randomized controlled trials for either singleton or multiple pregnancies [36–40].

#### **7.3 Are there any interventions to extend the duration of multiple pregnancy?**

There is no evidence that interventions such as prophylactic cerclage, routine hospitalization and bed rest, prophylactic tocolysis, and prophylactic pessary reduce neonatal morbidity and mortality. Hence, their use is not recommended in multiple pregnancy.

#### *7.3.1 Prophylactic cerclage*

The benefit of prophylactic cerclage in a twin or triplet pregnancy without a history of cervical insufficiency has not been shown [41–43]. In addition, prophylactic cerclage has been reported to increase spontaneous preterm labor by twofold in pregnant women with a short cervical canal on ultrasound (RR, 2.2; 95% [CI], 1.2–4.0) [44, 45]. Therefore, cerclage should be avoided in multiple pregnancies.

#### *7.3.2 Routine hospitalization and bed rest*

In a Cochrane review, hospitalization or bed rest has been shown to have no benefit in uncomplicated twin pregnancies [46]. For this reason, routine bed rest should not be recommended to women pregnant with multiples due to the lack of benefit and the risk of thrombosis.

#### *7.3.3 Prophylactic tocolysis*

No tocolytic agent should be used for prophylaxis in multiple pregnancies. Maternal complications from tocolysis, such as pulmonary edema, are more common in multiple pregnancies [47, 48]. There are also no data that these drugs reduce the risk of preterm labor or improve neonatal outcomes [49–51]. Oral betamimetics did not reduce preterm delivery, low birth weight, or neonatal mortality in multiple pregnancies compared to placebo [52]. Oral betamimetics are also associated with maternal and fetal cardiac stress and gestational diabetes [53, 54]. It has recently been demonstrated to be associated with adverse maternal cardiovascular events, including death [55].

#### *7.3.4 Prophylactic pessary*

There is no scientific evidence that prophylactic cervical pessary reduces the frequency of spontaneous preterm labor or perinatal morbidity in multiple

**85**

woman [80].

*Multifetal Gestations*

**pregnancies?**

*7.5.1 Tocolytics*

corticosteroids.

*7.5.2 Corticosteroids*

the number of fetuses [70, 71].

*7.5.3 Magnesium sulfate for fetal neuroprotection*

**7.6 Prenatal screening in multiple pregnancies**

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

pessary is not recommended in multiple pregnancies [56].

progesterone has been demonstrated to be beneficial [64–67].

**7.5 How to manage preterm labor in multiple pregnancies?**

pregnancies. In a recent multicenter randomized controlled study, 813 twin pregnancies from 16 to 20 weeks were randomized [56], and poor perinatal outcome was observed in at least 1 baby of 13% of women treated by Arabin pessary and 14% of other women (RR, 0.98 CI 0.69–1.39). Therefore, the use of prophylactic cervical

**7.4 Does progesterone treatment reduce the risk of preterm labor in multiple** 

Progesterone treatment is not recommended in multiple pregnancies since it does not decrease the incidence of preterm labor [57–63]. In one study, it was shown that the use of 17α-hydroxyprogesterone caproate did not reduce neonatal morbidity and prolong pregnancy in triplet pregnancies [61]. In another randomized study, it was shown to significantly increase the rates of fetal loss in the second trimester in triplets [60]. In multiple pregnancies that the cervix was found to be short on transvaginal ultrasound, neither 17α-hydroxyprogesterone caproate nor vaginal

Calcium channel blockers or nonsteroidal anti-inflammatory drugs are first-line tocolytic agents. Although there are no large-scale randomized studies conducted only with multiple pregnancies, the current scientific data were obtained from studies involving multiple pregnancies as well as singleton pregnancies [68]. Therefore, in case of an acute preterm labor in multiple pregnancies, short-term tocolysis can be administered up to 48 hours to allow for the administration of

In a Cochrane review, it was concluded that antenatal corticosteroid is beneficial in singleton pregnancies and further studies are required for the outcomes in multiple pregnancies [69]. However, based on its proven benefits in singleton pregnancies, the National Institute of Health recommends the administration of antenatal corticosteroids to pregnant women from 24 to 34 weeks of gestation and who are at risk of giving birth within 7 days, unless there is a contraindication, regardless of

Magnesium sulfate has been shown to reduce the risk and severity of cerebral

In multiple pregnancies, the probability of one or more fetuses being affected by trisomy is mathematically higher than in singleton pregnancies. For example, maternal age-dependent risk of trisomy in dizygotic twins is twice as much as a singleton pregnancy at the same age [79]. Therefore, the risk of a 33-year-old woman expecting twins is equal to that of a 35-year-old singleton pregnant

palsy, regardless of the number of fetuses, at birth before 32 weeks [72–78].

#### *Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

pregnancies. In a recent multicenter randomized controlled study, 813 twin pregnancies from 16 to 20 weeks were randomized [56], and poor perinatal outcome was observed in at least 1 baby of 13% of women treated by Arabin pessary and 14% of other women (RR, 0.98 CI 0.69–1.39). Therefore, the use of prophylactic cervical pessary is not recommended in multiple pregnancies [56].

#### **7.4 Does progesterone treatment reduce the risk of preterm labor in multiple pregnancies?**

Progesterone treatment is not recommended in multiple pregnancies since it does not decrease the incidence of preterm labor [57–63]. In one study, it was shown that the use of 17α-hydroxyprogesterone caproate did not reduce neonatal morbidity and prolong pregnancy in triplet pregnancies [61]. In another randomized study, it was shown to significantly increase the rates of fetal loss in the second trimester in triplets [60]. In multiple pregnancies that the cervix was found to be short on transvaginal ultrasound, neither 17α-hydroxyprogesterone caproate nor vaginal progesterone has been demonstrated to be beneficial [64–67].

#### **7.5 How to manage preterm labor in multiple pregnancies?**

#### *7.5.1 Tocolytics*

*Family Planning and Reproductive Health*

preterm labor [34].

multiple pregnancy.

*7.3.1 Prophylactic cerclage*

*7.3.2 Routine hospitalization and bed rest*

benefit and the risk of thrombosis.

*7.3.3 Prophylactic tocolysis*

*7.3.4 Prophylactic pessary*

**7.2 Is there a test to predict spontaneous preterm labor in multiple pregnancies?**

In order to determine the risk of spontaneous preterm labor in asymptomatic pregnant women, many screening methods such as measuring cervical canal length with transvaginal ultrasound, examination of the cervix, fetal fibronectin screening, and home uterus monitoring have been tried. These screening methods are not recommended in asymptomatic women because there is no intervention that can prevent preterm labor in multiple pregnancies that are found to be at high risk for

In symptomatic pregnant women, the positive predictive value of fetal fibronectin test alone or short cervical length is low and should not be used for the management of acute symptoms [35]. Although observational studies have shown that fetal fibronectin or cervical canal length precludes the use of unnecessary treatment in singleton pregnancies with preterm labor symptoms, these data have not been proven by randomized controlled trials for either singleton or multiple pregnancies [36–40].

**7.3 Are there any interventions to extend the duration of multiple pregnancy?**

There is no evidence that interventions such as prophylactic cerclage, routine hospitalization and bed rest, prophylactic tocolysis, and prophylactic pessary reduce neonatal morbidity and mortality. Hence, their use is not recommended in

The benefit of prophylactic cerclage in a twin or triplet pregnancy without a history of cervical insufficiency has not been shown [41–43]. In addition, prophylactic cerclage has been reported to increase spontaneous preterm labor by twofold in pregnant women with a short cervical canal on ultrasound (RR, 2.2; 95% [CI], 1.2–4.0) [44, 45]. Therefore, cerclage should be avoided in multiple pregnancies.

In a Cochrane review, hospitalization or bed rest has been shown to have no benefit in uncomplicated twin pregnancies [46]. For this reason, routine bed rest should not be recommended to women pregnant with multiples due to the lack of

No tocolytic agent should be used for prophylaxis in multiple pregnancies. Maternal complications from tocolysis, such as pulmonary edema, are more common in multiple pregnancies [47, 48]. There are also no data that these drugs reduce the risk of preterm labor or improve neonatal outcomes [49–51]. Oral betamimetics did not reduce preterm delivery, low birth weight, or neonatal mortality in multiple pregnancies compared to placebo [52]. Oral betamimetics are also associated with maternal and fetal cardiac stress and gestational diabetes [53, 54]. It has recently been demonstrated to be associated with adverse maternal cardiovascular events, including death [55].

There is no scientific evidence that prophylactic cervical pessary reduces the frequency of spontaneous preterm labor or perinatal morbidity in multiple

**84**

Calcium channel blockers or nonsteroidal anti-inflammatory drugs are first-line tocolytic agents. Although there are no large-scale randomized studies conducted only with multiple pregnancies, the current scientific data were obtained from studies involving multiple pregnancies as well as singleton pregnancies [68]. Therefore, in case of an acute preterm labor in multiple pregnancies, short-term tocolysis can be administered up to 48 hours to allow for the administration of corticosteroids.

#### *7.5.2 Corticosteroids*

In a Cochrane review, it was concluded that antenatal corticosteroid is beneficial in singleton pregnancies and further studies are required for the outcomes in multiple pregnancies [69]. However, based on its proven benefits in singleton pregnancies, the National Institute of Health recommends the administration of antenatal corticosteroids to pregnant women from 24 to 34 weeks of gestation and who are at risk of giving birth within 7 days, unless there is a contraindication, regardless of the number of fetuses [70, 71].

#### *7.5.3 Magnesium sulfate for fetal neuroprotection*

Magnesium sulfate has been shown to reduce the risk and severity of cerebral palsy, regardless of the number of fetuses, at birth before 32 weeks [72–78].

#### **7.6 Prenatal screening in multiple pregnancies**

In multiple pregnancies, the probability of one or more fetuses being affected by trisomy is mathematically higher than in singleton pregnancies. For example, maternal age-dependent risk of trisomy in dizygotic twins is twice as much as a singleton pregnancy at the same age [79]. Therefore, the risk of a 33-year-old woman expecting twins is equal to that of a 35-year-old singleton pregnant woman [80].

Aneuploidy screening has many limitations in multiple pregnancies. Serum screening tests in twin or triplet pregnancies are not as sensitive as in singleton pregnancies. The detection rate of trisomy 21 by the second trimester maternal serum screening test in twin pregnancies has been reported to be 63% (71% when both fetuses are affected and 60% when only one is affected) with a false-positive rate of 10.8% [81]. In the first trimester screening test, where maternal age, nuchal transparency, and biochemical markers are evaluated together in twin pregnancies, the detection rate is 75–85% for Down syndrome and 66.7% for trisomy 18, with a false-positive rate of 5% [82–85]. Experience with triplet pregnancies is scarce, but studies show that screening for only nuchal transparency and maternal age is reliable. However, one study has shown that the nuchal transparency above the 95th percentile in monochorionic twin pregnancies predicts 38% of twinto-twin transfusion syndrome that will develop later, making the interpretation of the first trimester screening results even more complicated in monochorionic pregnancies [86].

Noninvasive prenatal testing can be used for fetal aneuploidy screening, but further data is required to recommend its use in multiple pregnancies [87].

#### **7.7 What are the problems encountered in the prenatal diagnosis of aneuploidy in multiple pregnancies?**

Women who wish to have a definitive diagnosis of genetic abnormalities may have an amniocentesis and chorionic villus sampling (CVS). The procedure-related risk of miscarriage for both tests is similar (1–1.8%) and slightly higher compared to singleton pregnancies [88–90]. The main advantage of having CVS is that CVS is performed earlier in pregnancy. However, in multiple pregnancies, some technical difficulties are encountered during these procedures. In approximately 1% of multiple pregnancies, sample for CVS was collected from the wrong fetus [91]. This risk is lower in amniocentesis. To avoid the risk of sampling error, indigo carmine is injected into the first sampled sac after amniocentesis. The absence of dye in the fluid from the second sac proves that sampling was done from two different sacs. Due to the low probability of karyotype being discordant in monochorionic twins, pregnant women may prefer karyotype analysis of a single fetus. Thus, the success of ultrasound in determining chorionicity should be explained to pregnant women.

When aneuploidy is diagnosed, if a fetus is affected, the parents are offered several options, such as termination of the entire pregnancy, selective reduction of the affected fetus, or continuation of pregnancy without any intervention.

#### **7.8 What is the prognosis of multiple pregnancies that are discordant in terms of the size of the fetuses?**

Discordant growth in multiple pregnancies is generally defined as a difference of at least 20% between the estimated fetal weights of two fetuses [92, 93]. This rate is calculated by dividing the difference between the weights of the two fetuses by the weight of the larger fetus. It is controversial whether growth discordance leads to negative outcomes in the absence of structural anomaly, aneuploidy, discordant infection, oligohydramnios, or fetal growth restriction. There are studies showing that fetal or neonatal morbidity and mortality do not increase in cases where weight discordance is present but the weight of both fetuses complies with that gestational week [94–97]. However, in multiple pregnancies where the growth of at least one fetus is limited, major neonatal morbidity increases by 7.7 times [98]. In addition, perinatal mortality and morbidity rates were higher in twins with growth restriction than in singleton pregnancies in the same gestational week [99]. In summary,

**87**

[113–115].

*7.11.1 Twin-to-twin transfusion syndrome*

*Multifetal Gestations*

discordance.

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

**7.9 How to manage the death of a fetus?**

although there is no evidence that neonatal morbidity and mortality increase in twins with discordance only, the risk of adverse perinatal outcomes increases in the presence of an abnormal finding such as fetal growth restriction accompanied by

In the first trimester, spontaneous reduction occurs in one or more fetuses in many of the multiple pregnancies [100]. This likelihood of reduction is proportional to the number of gestational sacs (36% in twins, 53% in triplets, 65% in quadruplets [101]). In the second or third trimester, the death of one or more fetuses is seen in 5% of twins and 17% of triplets [102]. Chorionicity affects the loss rate and helps determine the prognosis and manage the living fetus. In monochorionicdiamniotic twins, the rate of fetal death is higher than in dichorionic-diamniotic twins [103–105]. In fetal deaths after the 14th week of pregnancy, the probability of death of the other twin is 15% in monochorionic twins and 3% in dichorionic twins [105]. The probability of developing neurological abnormalities in the living fetus is 18% in monochorionic twins and 1% in dichorionic twins [106, 107]. Despite these risks, the immediate delivery of the other twin has no benefit [108]. Therefore, in monochorionic twin pregnancies, if one of the fetuses dies before the 34th gestational week, the pregnancy should be managed according to the mother and the living fetus. Unless there is another indication, delivery should not be done before 34th week [109]. The timing of birth should be determined according to the patient

and in consultation with those trained in maternal-fetal medicine.

pregnancy complications every 4–6 weeks with serial ultrasound.

fetal or maternal complications such as fetal growth restriction.

**7.10 How to perform antepartum fetal follow-up in dichorionic pregnancies?**

After determining chorionicity in the first or early second trimester, the anatomy, size, amount of amniotic fluid, and placenta should be evaluated with ultrasound at 18–22 weeks of gestation. The growth rate of fetuses in uncomplicated twin pregnancies is approximately the same as single pregnancies up to 28–32 weeks [110]. Although there is no scientific evidence suggesting that ultrasound should be performed to evaluate fetal growth after the 20th week, it seems reasonable to monitor dichorionic twin pregnancies without fetal growth restriction or other

It has not been shown that antepartum tests or umbilical artery Doppler ultrasound improves perinatal outcomes in uncomplicated twin pregnancies [111]. Tests evaluating fetal well-being in dichorionic twins should only be used when there are

Monochorionic pregnancies should be monitored more closely than dichorionic twins because of the higher risk of complications [112]. Monitoring of pregnancy with serial ultrasound every 2 weeks from the 16th week should be considered

Twin-to-twin transfusion syndrome develops in approximately 10–15% of monochorionic-diamniotic pregnancies and is due to arteriovenous anastomoses in the monochorionic placenta. It usually occurs in the second trimester and is diagnosed by the presence of oligohydramnios (the largest vertical pocket is smaller

**7.11 How to manage complications caused by monochorionic placentation?**

*Family Planning and Reproductive Health*

pregnancies [86].

**in multiple pregnancies?**

**the size of the fetuses?**

Aneuploidy screening has many limitations in multiple pregnancies. Serum screening tests in twin or triplet pregnancies are not as sensitive as in singleton pregnancies. The detection rate of trisomy 21 by the second trimester maternal serum screening test in twin pregnancies has been reported to be 63% (71% when both fetuses are affected and 60% when only one is affected) with a false-positive rate of 10.8% [81]. In the first trimester screening test, where maternal age, nuchal transparency, and biochemical markers are evaluated together in twin pregnancies, the detection rate is 75–85% for Down syndrome and 66.7% for trisomy 18, with a false-positive rate of 5% [82–85]. Experience with triplet pregnancies is scarce, but studies show that screening for only nuchal transparency and maternal age is reliable. However, one study has shown that the nuchal transparency above the 95th percentile in monochorionic twin pregnancies predicts 38% of twinto-twin transfusion syndrome that will develop later, making the interpretation of the first trimester screening results even more complicated in monochorionic

Noninvasive prenatal testing can be used for fetal aneuploidy screening, but

**7.7 What are the problems encountered in the prenatal diagnosis of aneuploidy** 

Women who wish to have a definitive diagnosis of genetic abnormalities may have an amniocentesis and chorionic villus sampling (CVS). The procedure-related risk of miscarriage for both tests is similar (1–1.8%) and slightly higher compared to singleton pregnancies [88–90]. The main advantage of having CVS is that CVS is performed earlier in pregnancy. However, in multiple pregnancies, some technical difficulties are encountered during these procedures. In approximately 1% of multiple pregnancies, sample for CVS was collected from the wrong fetus [91]. This risk is lower in amniocentesis. To avoid the risk of sampling error, indigo carmine is injected into the first sampled sac after amniocentesis. The absence of dye in the fluid from the second sac proves that sampling was done from two different sacs. Due to the low probability of karyotype being discordant in monochorionic twins, pregnant women may prefer karyotype analysis of a single fetus. Thus, the success of ultrasound in determining chorionicity should be explained to pregnant women. When aneuploidy is diagnosed, if a fetus is affected, the parents are offered several options, such as termination of the entire pregnancy, selective reduction of

further data is required to recommend its use in multiple pregnancies [87].

the affected fetus, or continuation of pregnancy without any intervention.

**7.8 What is the prognosis of multiple pregnancies that are discordant in terms of** 

Discordant growth in multiple pregnancies is generally defined as a difference of at least 20% between the estimated fetal weights of two fetuses [92, 93]. This rate is calculated by dividing the difference between the weights of the two fetuses by the weight of the larger fetus. It is controversial whether growth discordance leads to negative outcomes in the absence of structural anomaly, aneuploidy, discordant infection, oligohydramnios, or fetal growth restriction. There are studies showing that fetal or neonatal morbidity and mortality do not increase in cases where weight discordance is present but the weight of both fetuses complies with that gestational week [94–97]. However, in multiple pregnancies where the growth of at least one fetus is limited, major neonatal morbidity increases by 7.7 times [98]. In addition, perinatal mortality and morbidity rates were higher in twins with growth restriction than in singleton pregnancies in the same gestational week [99]. In summary,

**86**

although there is no evidence that neonatal morbidity and mortality increase in twins with discordance only, the risk of adverse perinatal outcomes increases in the presence of an abnormal finding such as fetal growth restriction accompanied by discordance.

#### **7.9 How to manage the death of a fetus?**

In the first trimester, spontaneous reduction occurs in one or more fetuses in many of the multiple pregnancies [100]. This likelihood of reduction is proportional to the number of gestational sacs (36% in twins, 53% in triplets, 65% in quadruplets [101]). In the second or third trimester, the death of one or more fetuses is seen in 5% of twins and 17% of triplets [102]. Chorionicity affects the loss rate and helps determine the prognosis and manage the living fetus. In monochorionicdiamniotic twins, the rate of fetal death is higher than in dichorionic-diamniotic twins [103–105]. In fetal deaths after the 14th week of pregnancy, the probability of death of the other twin is 15% in monochorionic twins and 3% in dichorionic twins [105]. The probability of developing neurological abnormalities in the living fetus is 18% in monochorionic twins and 1% in dichorionic twins [106, 107]. Despite these risks, the immediate delivery of the other twin has no benefit [108]. Therefore, in monochorionic twin pregnancies, if one of the fetuses dies before the 34th gestational week, the pregnancy should be managed according to the mother and the living fetus. Unless there is another indication, delivery should not be done before 34th week [109]. The timing of birth should be determined according to the patient and in consultation with those trained in maternal-fetal medicine.

#### **7.10 How to perform antepartum fetal follow-up in dichorionic pregnancies?**

After determining chorionicity in the first or early second trimester, the anatomy, size, amount of amniotic fluid, and placenta should be evaluated with ultrasound at 18–22 weeks of gestation. The growth rate of fetuses in uncomplicated twin pregnancies is approximately the same as single pregnancies up to 28–32 weeks [110]. Although there is no scientific evidence suggesting that ultrasound should be performed to evaluate fetal growth after the 20th week, it seems reasonable to monitor dichorionic twin pregnancies without fetal growth restriction or other pregnancy complications every 4–6 weeks with serial ultrasound.

It has not been shown that antepartum tests or umbilical artery Doppler ultrasound improves perinatal outcomes in uncomplicated twin pregnancies [111]. Tests evaluating fetal well-being in dichorionic twins should only be used when there are fetal or maternal complications such as fetal growth restriction.

#### **7.11 How to manage complications caused by monochorionic placentation?**

Monochorionic pregnancies should be monitored more closely than dichorionic twins because of the higher risk of complications [112]. Monitoring of pregnancy with serial ultrasound every 2 weeks from the 16th week should be considered [113–115].

#### *7.11.1 Twin-to-twin transfusion syndrome*

Twin-to-twin transfusion syndrome develops in approximately 10–15% of monochorionic-diamniotic pregnancies and is due to arteriovenous anastomoses in the monochorionic placenta. It usually occurs in the second trimester and is diagnosed by the presence of oligohydramnios (the largest vertical pocket is smaller than 2 cm) in one sac and polyhydramnios (the largest vertical pocket is larger than 8 cm) in the other sac. A fetal discordance and selective fetal growth restriction due to structural and genetic anomalies or infectious diseases should be ruled out. The benefits of umbilical artery Doppler have not been demonstrated in cases where there is no growth and fluid discordance. The prognosis of twin-to-twin transfusion syndrome varies by the week of gestation and the severity of the syndrome. Staging is based on the Quintero classification system shown in **Table 1**, and treatment with laser coagulation or amnioreduction therapy is frequently used [112, 116].

#### *7.11.2 Monoamniotic twins*

The natural incidence of monoamniotic twin pregnancy is one in 10,000, but the incidence may be higher in zona-manipulated IVF pregnancies [117]. Perinatal mortality rates associated with cord complications have been reported as high as 80% [118]. Although the ideal management of these pregnancies is not clearly known, daily fetal heart monitoring in hospital conditions from 24 to 28 weeks of gestation and delivery at 32–34 weeks of gestation are the common practice [118–120].

#### *7.11.3 Rare complications*

Acardiac twin pregnancy occurs in 1% of monochorionic pregnancies and is characterized with a fetus that does not have a normally developed heart and brain [121]. This fetus continues to live by the anastomoses in the placenta and the blood supplied by the other fetus (pumping twin). Therefore, the pumping fetus is at risk of cardiac insufficiency, and intrauterine or neonatal loss occurs in nearly half of the cases [122]. This rare condition should be managed by a maternal-fetal medicine specialist experienced in twin pregnancy management.

Conjoined twin is a rare phenomenon, occurring 1 in 50,000–100,000 [123]. After the diagnosis, it should be determined which organs are shared for the prognosis [124]. The survival rate of a conjoined twin detected in the intrauterine period is only 18% even after successful surgery [125].

#### **7.12 What should be the time and mode of delivery in multiple pregnancies?**

The time of spontaneous delivery in twin pregnancies is around 36 weeks, and so the complications of prematurity are an important risk [126]. Perinatal mortality increases again after 38 weeks of gestation [127]. Accordingly the time of delivery for uncomplicated twin pregnancies would be reasonable [108]:


The ideal mode of delivery varies by the type of twin pregnancy, the presentation of the fetuses, the gestational week, and the experience of the delivering physician. Twin pregnancy alone is not an indication of cesarean section [128]. In monoamniotic pregnancies only, cesarean delivery is required to avoid cord complications that may develop in the other fetus during the birth of the first fetus [118].

**89**

*Multifetal Gestations*

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

in internal podalic version and vaginal breech delivery [130].

In a recently published randomized controlled study, no difference was reported between planned cesarean and planned vaginal delivery in terms of fetal and neonatal death or severe neonatal morbidity between 32 and 38 6/7 weeks of gestation in twin pregnancies with cephalic presentation of the first fetus [129]. Therefore, in diamniotic twin pregnancies with cephalic presentation of the first fetus after the 32nd gestational week, vaginal delivery appears to be a logical option, regardless of the presentation of the second fetus, provided that the obstetrician is experienced

The ideal delivery method in higher-order multiple pregnancies is not known. In small observational studies, there was no significant difference between planned vaginal delivery and planned cesarean delivery with the cephalic presentation of the first fetus in uncomplicated triplet pregnancies. Therefore, planned vaginal delivery may be considered in these pregnancies if obstetrician is experienced [131–133]. Vaginal delivery can be attempted in twin pregnancies with a previous history of cesarean section with a single lower transverse incision and without any contraindications for vaginal delivery [134–138]. Internal fetal manipulation or emergency cesarean section may be required during delivery. Women with multiple pregnancies are at risk for atony, postpartum bleeding, and emergency hysterectomy [139]. The administration of neuroaxial analgesia facilitates operative vaginal delivery, external or internal

cephalic version, and total breech extraction in multiple pregnancies [130].

Stage 1. Monochorionic-diamniotic gestation with oligohydramnios (MVP less than 2 cm) and

**A.** Recommendations based on reliable scientific data (with evidence level A)

*Defined as the presence of one or more of the following: umbilical artery absent or reversed diastolic flow; ductus* 

• Treatment with progesterone does not reduce the incidence of spontaneous

• No tocolytic agent is recommended for prophylactic use in multiple

**B.** Recommendations based on limited scientific data (with evidence level B)

• Chorionicity should be determined in the late stages of the first trimester or in the early stages of the second trimester due to complications of

• Since prophylactic tocolysis, prophylactic cerclage, prophylactic pessary, routine hospitalization, and bed rest have not been shown to reduce neonatal

**8. Summary of findings and recommendations**

*venosus absent or reversed diastolic flow; or umbilical vein pulsatile flow.*

polyhydramnios (MVP greater than 8 cm)

Stage 3. Abnormal Doppler ultrasonography findings\*

*Abbreviation: MVP, maximum vertical pocket. Data from [140].*

Stage 2. Absent (empty) bladder in donor

Stage 5. Death of one or both twins

*Staging of twin-to-twin transfusion syndrome.*

Stage 4. Hydrops

*\**

**Table 1.**

preterm delivery in twin and triplet pregnancies.

pregnancies.

monochorionicity.

#### *Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

*Family Planning and Reproductive Health*

*7.11.2 Monoamniotic twins*

*7.11.3 Rare complications*

complications

[118–120].

than 2 cm) in one sac and polyhydramnios (the largest vertical pocket is larger than 8 cm) in the other sac. A fetal discordance and selective fetal growth restriction due to structural and genetic anomalies or infectious diseases should be ruled out. The benefits of umbilical artery Doppler have not been demonstrated in cases where there is no growth and fluid discordance. The prognosis of twin-to-twin transfusion syndrome varies by the week of gestation and the severity of the syndrome. Staging is based on the Quintero classification system shown in **Table 1**, and treatment with

The natural incidence of monoamniotic twin pregnancy is one in 10,000, but the incidence may be higher in zona-manipulated IVF pregnancies [117]. Perinatal mortality rates associated with cord complications have been reported as high as 80% [118]. Although the ideal management of these pregnancies is not clearly known, daily fetal heart monitoring in hospital conditions from 24 to 28 weeks of gestation and delivery at 32–34 weeks of gestation are the common practice

Acardiac twin pregnancy occurs in 1% of monochorionic pregnancies and is characterized with a fetus that does not have a normally developed heart and brain [121]. This fetus continues to live by the anastomoses in the placenta and the blood supplied by the other fetus (pumping twin). Therefore, the pumping fetus is at risk of cardiac insufficiency, and intrauterine or neonatal loss occurs in nearly half of the cases [122]. This rare condition should be managed by a maternal-fetal medicine

Conjoined twin is a rare phenomenon, occurring 1 in 50,000–100,000 [123]. After the diagnosis, it should be determined which organs are shared for the prognosis [124]. The survival rate of a conjoined twin detected in the intrauterine period

**7.12 What should be the time and mode of delivery in multiple pregnancies?**

a.At 38 weeks in dichorionic diamniotic twins without complications

The time of spontaneous delivery in twin pregnancies is around 36 weeks, and so the complications of prematurity are an important risk [126]. Perinatal mortality increases again after 38 weeks of gestation [127]. Accordingly the time of delivery

b.From 34 to 37 6/7 weeks in monochorionic-diamniotic pregnancies without

c.From 32 to 34 weeks in monoamniotic pregnancies without complications

The ideal mode of delivery varies by the type of twin pregnancy, the presentation of the fetuses, the gestational week, and the experience of the delivering physician. Twin pregnancy alone is not an indication of cesarean section [128]. In monoamniotic pregnancies only, cesarean delivery is required to avoid cord complications that may develop in the other fetus during the birth of the first

specialist experienced in twin pregnancy management.

for uncomplicated twin pregnancies would be reasonable [108]:

is only 18% even after successful surgery [125].

laser coagulation or amnioreduction therapy is frequently used [112, 116].

**88**

fetus [118].

In a recently published randomized controlled study, no difference was reported between planned cesarean and planned vaginal delivery in terms of fetal and neonatal death or severe neonatal morbidity between 32 and 38 6/7 weeks of gestation in twin pregnancies with cephalic presentation of the first fetus [129]. Therefore, in diamniotic twin pregnancies with cephalic presentation of the first fetus after the 32nd gestational week, vaginal delivery appears to be a logical option, regardless of the presentation of the second fetus, provided that the obstetrician is experienced in internal podalic version and vaginal breech delivery [130].

The ideal delivery method in higher-order multiple pregnancies is not known. In small observational studies, there was no significant difference between planned vaginal delivery and planned cesarean delivery with the cephalic presentation of the first fetus in uncomplicated triplet pregnancies. Therefore, planned vaginal delivery may be considered in these pregnancies if obstetrician is experienced [131–133]. Vaginal delivery can be attempted in twin pregnancies with a previous history of cesarean section with a single lower transverse incision and without any contraindications for vaginal delivery [134–138]. Internal fetal manipulation or emergency cesarean section may be required during delivery. Women with multiple pregnancies are at risk for atony, postpartum bleeding, and emergency hysterectomy [139]. The administration of neuroaxial analgesia facilitates operative vaginal delivery, external or internal cephalic version, and total breech extraction in multiple pregnancies [130].


#### **Table 1.**

*Staging of twin-to-twin transfusion syndrome.*

#### **8. Summary of findings and recommendations**

**A.** Recommendations based on reliable scientific data (with evidence level A)

	- Chorionicity should be determined in the late stages of the first trimester or in the early stages of the second trimester due to complications of monochorionicity.
	- Since prophylactic tocolysis, prophylactic cerclage, prophylactic pessary, routine hospitalization, and bed rest have not been shown to reduce neonatal

morbidity and mortality, these practices are not recommended in multiple pregnancies.


**C.** Recommendations based on expert opinion (with evidence level C)


**91**

**Author details**

Department of Obstetrics and Gynecology, Osmaniye State Hospital, Osmaniye,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: ilkankayar@gmail.com

provided the original work is properly cited.

Ilkan Kayar

Turkey

*Multifetal Gestations*

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

• Monoamniotic twin pregnancies should be delivered by cesarean.

*Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

*Family Planning and Reproductive Health*

another contraindication.

ous twin pregnancies.

number of fetuses.

screening regardless of age.

and total breech extraction.

gestation.

pregnancies.

morbidity and mortality, these practices are not recommended in multiple

• Magnesium sulfate has been shown to reduce the risk and severity of cerebral

• In women with a previous history of cesarean section with a transverse incision to the lower segment, vaginal delivery can be attempted unless there is

• In pregnancies in which the number of fetuses is reduced from three to two with embryo reduction, pregnancy loss, antenatal complications, preterm delivery, low birth weight, and cesarean and neonatal mortality rates are lower than in pregnancies continuing as triplets and are similar to spontane-

• Unless there are contraindications, a cycle of antenatal corticosteroid should be administered to women pregnant with multiples from 24 to 34 weeks of gestation and who are expected to give birth within 7 days regardless of the

• Delivery in uncomplicated monoamniotic twins should be at 32–34 weeks of

• In diamniotic twin pregnancies over 32 0/7 weeks with cephalic presentation of the first fetus, vaginal delivery appears to be a logical option, regardless of the presentation of the second fetus, provided that the obstetrician is experienced in internal podalic version and vaginal breech delivery.

• Women with multiple pregnancies are candidates for routine aneuploidy

• Administration of neuroaxial (epidural) analgesia in multiple pregnancies facilitates operative vaginal delivery, external or internal cephalic version,

• Monoamniotic twin pregnancies should be delivered by cesarean.

**C.** Recommendations based on expert opinion (with evidence level C)

palsy, regardless of the number of fetuses, at birth before 32 weeks.

**90**

#### **Author details**

Ilkan Kayar Department of Obstetrics and Gynecology, Osmaniye State Hospital, Osmaniye, Turkey

\*Address all correspondence to: ilkankayar@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Martin JA, Hamilton BE, Osterman MJ. Three decades of twin births in the United States, 1980-2009. NCHS Data Brief. 2012;**80**:1-8

[2] Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Kirmeyer S, Mathews TJ, et al. Births: Final data for 2009. National Vital Statistics Reports. 2011;**60**:1-70

[3] Blondel B, Kaminski M. Trends in the occurrence, determinants, and consequences of multiple births. Seminars in Perinatology. 2002;**26**:239-249

[4] Scher AI, Petterson B, Blair E, Ellenberg JH, Grether JK, Haan E, et al. The risk of mortality or cerebral palsy in twins: A collaborative populationbased study. Pediatric Research. 2002;**52**:671-681

[5] Rettwitz-Volk W, Tran TM, Veldman A. Cerebral morbidity in preterm twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2003;**13**:218-223

[6] Yokoyama Y, Shimizu T, Hayakawa K. Prevalence of cerebral palsy in twins, triplets and quadruplets. International Journal of Epidemiology. 1995;**24**:943-948

[7] Bromer JG, Ata B, Seli M, Lockwood CJ, Seli E. Preterm deliveries that result from multiple pregnancies associated with assisted reproductive technologies in the USA: A cost analysis. Current Opinion in Obstetrics & Gynecology. 2011;**23**:168-173

[8] Institute of Medicine. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: National Academies Press; 2007

[9] LeFevre ML, Bain RP, Ewigman BG, Frigoletto FD, Crane JP, McNellis D.

A randomized trial of prenatal ultrasonographic screening: Impact on maternal management and outcome. RADIUS (Routine Antenatal Diagnostic Imaging with Ultrasound) Study Group. American Journal of Obstetrics and Gynecology. 1993;**169**:483-489

[10] Geipel A, Berg C, Katalinic A, Plath H, Hansmann M, Germer U, et al. Prenatal diagnosis and obstetric outcomes in triplet pregnancies in relation to chorionicity. BJOG. 2005;**112**:554-558

[11] Glinianaia SV, Obeysekera MA, Sturgiss S, Bell R. Stillbirth and neonatal mortality in monochorionic and dichorionic twins: A populationbased study. Human Reproduction. 2011;**26**:2549-2557

[12] Bajoria R, Ward SB, Adegbite AL. Comparative study of perinatal outcome of dichorionic and trichorionic iatrogenic triplets. American Journal of Obstetrics and Gynecology. 2006;**194**:415-424

[13] Kawaguchi H, Ishii K, Yamamoto R, Hayashi S, Mitsuda N. Perinatal death of triplet pregnancies by chorionicity. Perinatal Research Network Group in Japan. American Journal of Obstetrics and Gynecology. 2013;**209**:36.e1-36.e7

[14] Sivan E, Maman E, Homko CJ, Lipitz S, Cohen S, Schiff E. Impact of fetal reduction on the incidence of gestational diabetes. Obstetrics and Gynecology. 2002;**99**:91-94

[15] Schwartz DB, Daoud Y, Zazula P, Goyert G, Bronsteen R, Wright D, et al. Gestational diabetes mellitus: Metabolic and blood glucose parameters in singleton versus twin pregnancies. American Journal of Obstetrics and Gynecology. 1999;**181**:912-914

**93**

*Multifetal Gestations*

2000;**182**:938-942

2007;**88**:283-293

2000;**95**:899-904

2007;**22**:2058-2065

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

[24] Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstetrics and

[25] Society for Assisted Reproductive Technology. Clinic Summary Report: All SART Member Clinics. Available from: https://www.sartcorsonline. com/rptCSR\_PublicMultYear. aspx?ClinicPKID=0 [Accessed: 05

[26] Dodd JM, Crowther CA. Reduction

of the number of fetuses for women with a multiple pregnancy. Cochrane Database of Systematic Reviews. 2012;(10):CD003932. DOI: 10.1002/14651858.CD003932.pub3

[27] Smith-Levitin M, Kowalik A, Birnholz J, Skupski DW, Hutson JM, Chervenak FA, et al. Selective reduction of multifetal pregnancies to twins improves outcome over nonreduced triplet gestations. American Journal of Obstetrics and Gynecology.

Gynecology. 2004;**103**:981-991

February 2014]

1996;**175**:878-882

2002;**187**:1168-1172

[28] Berkowitz RL, Stone JL, Eddleman KA. One hundred consecutive cases of selective termination of an abnormal fetus in a multifetal gestation. Obstetrics and

Gynecology. 1997;**90**:606-610

[29] Eddleman KA, Stone JL, Lynch L, Berkowitz RL. Selective termination of anomalous fetuses in multifetal pregnancies: Two hundred cases at a single center. American Journal of Obstetrics and Gynecology.

[30] Lust A, De Catte L, Lewi L, Deprest J, Loquet P, Devlieger R. Monochorionic and dichorionic twin pregnancies discordant for fetal anencephaly: A systematic review of prenatal management options. Prenatal Diagnosis. 2008;**28**:275-279

[16] Sibai BM, Hauth J, Caritis S, Lindheimer MD, MacPherson C, Klebanoff M, et al. Hypertensive disorders in twin versus singleton gestations. National Institute of Child Health and Human

Development Network of Maternal-Fetal Medicine Units. American Journal of Obstetrics and Gynecology.

[17] Luke B, Brown MB. Contemporary risks of maternal morbidity and adverse outcomes with increasing maternal age and plurality. Fertility and Sterility.

[18] Conde-Agudelo A, Belizan JM, Lindmark G. Maternal morbidity and mortality associated with multiple gestations. Obstetrics and Gynecology.

[19] Sheard C, Cox S, Oates M, Ndukwe G, Glazebrook C. Impact of a multiple, IVF birth on postpartum mental health: A composite analysis. Human Reproduction.

[20] Bailit JL. Hyperemesis gravidarium: Epidemiologic findings from a large cohort. American Journal of Obstetrics and Gynecology. 2005;**193**:811-814

[21] Day MC, Barton JR, O'Brien JM, Istwan NB, Sibai BM. The effect of fetal number on the development of hypertensive conditions of pregnancy.

[22] Lynch A, McDuffie R Jr, Murphy J, Faber K, Orleans M. Preeclampsia in multiple gestation: The role of assisted reproductive technologies. Obstetrics and Gynecology. 2002;**99**:445-451

[23] Hardardottir H, Kelly K, Bork MD, Cusick W, Campbell WA, Rodis JF. Atypical presentation of preeclampsia in high-order multifetal gestations. Obstetrics and Gynecology.

Obstetrics and Gynecology.

2005;**106**:927-931

1996;**87**:370-374

#### *Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

[16] Sibai BM, Hauth J, Caritis S, Lindheimer MD, MacPherson C, Klebanoff M, et al. Hypertensive disorders in twin versus singleton gestations. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. American Journal of Obstetrics and Gynecology. 2000;**182**:938-942

[17] Luke B, Brown MB. Contemporary risks of maternal morbidity and adverse outcomes with increasing maternal age and plurality. Fertility and Sterility. 2007;**88**:283-293

[18] Conde-Agudelo A, Belizan JM, Lindmark G. Maternal morbidity and mortality associated with multiple gestations. Obstetrics and Gynecology. 2000;**95**:899-904

[19] Sheard C, Cox S, Oates M, Ndukwe G, Glazebrook C. Impact of a multiple, IVF birth on postpartum mental health: A composite analysis. Human Reproduction. 2007;**22**:2058-2065

[20] Bailit JL. Hyperemesis gravidarium: Epidemiologic findings from a large cohort. American Journal of Obstetrics and Gynecology. 2005;**193**:811-814

[21] Day MC, Barton JR, O'Brien JM, Istwan NB, Sibai BM. The effect of fetal number on the development of hypertensive conditions of pregnancy. Obstetrics and Gynecology. 2005;**106**:927-931

[22] Lynch A, McDuffie R Jr, Murphy J, Faber K, Orleans M. Preeclampsia in multiple gestation: The role of assisted reproductive technologies. Obstetrics and Gynecology. 2002;**99**:445-451

[23] Hardardottir H, Kelly K, Bork MD, Cusick W, Campbell WA, Rodis JF. Atypical presentation of preeclampsia in high-order multifetal gestations. Obstetrics and Gynecology. 1996;**87**:370-374

[24] Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstetrics and Gynecology. 2004;**103**:981-991

[25] Society for Assisted Reproductive Technology. Clinic Summary Report: All SART Member Clinics. Available from: https://www.sartcorsonline. com/rptCSR\_PublicMultYear. aspx?ClinicPKID=0 [Accessed: 05 February 2014]

[26] Dodd JM, Crowther CA. Reduction of the number of fetuses for women with a multiple pregnancy. Cochrane Database of Systematic Reviews. 2012;(10):CD003932. DOI: 10.1002/14651858.CD003932.pub3

[27] Smith-Levitin M, Kowalik A, Birnholz J, Skupski DW, Hutson JM, Chervenak FA, et al. Selective reduction of multifetal pregnancies to twins improves outcome over nonreduced triplet gestations. American Journal of Obstetrics and Gynecology. 1996;**175**:878-882

[28] Berkowitz RL, Stone JL, Eddleman KA. One hundred consecutive cases of selective termination of an abnormal fetus in a multifetal gestation. Obstetrics and Gynecology. 1997;**90**:606-610

[29] Eddleman KA, Stone JL, Lynch L, Berkowitz RL. Selective termination of anomalous fetuses in multifetal pregnancies: Two hundred cases at a single center. American Journal of Obstetrics and Gynecology. 2002;**187**:1168-1172

[30] Lust A, De Catte L, Lewi L, Deprest J, Loquet P, Devlieger R. Monochorionic and dichorionic twin pregnancies discordant for fetal anencephaly: A systematic review of prenatal management options. Prenatal Diagnosis. 2008;**28**:275-279

**92**

Press; 2007

*Family Planning and Reproductive Health*

Osterman MJ. Three decades of twin births in the United States, 1980-2009. A randomized trial of prenatal

ultrasonographic screening: Impact on maternal management and outcome. RADIUS (Routine Antenatal Diagnostic Imaging with Ultrasound) Study Group. American Journal of Obstetrics and Gynecology. 1993;**169**:483-489

[10] Geipel A, Berg C, Katalinic A, Plath H, Hansmann M, Germer U, et al. Prenatal diagnosis and obstetric outcomes in triplet pregnancies in relation to chorionicity. BJOG.

[11] Glinianaia SV, Obeysekera MA, Sturgiss S, Bell R. Stillbirth and neonatal mortality in monochorionic and dichorionic twins: A populationbased study. Human Reproduction.

[12] Bajoria R, Ward SB, Adegbite AL. Comparative study of perinatal outcome

[13] Kawaguchi H, Ishii K, Yamamoto R, Hayashi S, Mitsuda N. Perinatal death

[14] Sivan E, Maman E, Homko CJ, Lipitz S, Cohen S, Schiff E. Impact of fetal reduction on the incidence of gestational diabetes. Obstetrics and

[15] Schwartz DB, Daoud Y, Zazula P, Goyert G, Bronsteen R, Wright D, et al. Gestational diabetes mellitus: Metabolic

and blood glucose parameters in singleton versus twin pregnancies. American Journal of Obstetrics and Gynecology. 1999;**181**:912-914

Gynecology. 2002;**99**:91-94

of dichorionic and trichorionic iatrogenic triplets. American Journal of Obstetrics and Gynecology.

2005;**112**:554-558

2011;**26**:2549-2557

2006;**194**:415-424

of triplet pregnancies by chorionicity. Perinatal Research Network Group in Japan. American Journal of Obstetrics and Gynecology.

2013;**209**:36.e1-36.e7

Ventura SJ, Osterman MJ, Kirmeyer S, Mathews TJ, et al. Births: Final data for 2009. National Vital Statistics Reports.

[3] Blondel B, Kaminski M. Trends in the occurrence, determinants, and consequences of multiple births. Seminars in Perinatology.

[4] Scher AI, Petterson B, Blair E, Ellenberg JH, Grether JK, Haan E, et al. The risk of mortality or cerebral palsy in twins: A collaborative populationbased study. Pediatric Research.

[5] Rettwitz-Volk W, Tran TM, Veldman A. Cerebral morbidity in preterm twins. The Journal of

[6] Yokoyama Y, Shimizu T,

[7] Bromer JG, Ata B, Seli M,

Maternal-Fetal & Neonatal Medicine.

Hayakawa K. Prevalence of cerebral palsy in twins, triplets and quadruplets. International Journal of Epidemiology.

Lockwood CJ, Seli E. Preterm deliveries that result from multiple pregnancies associated with assisted reproductive technologies in the USA: A cost analysis. Current Opinion in Obstetrics & Gynecology. 2011;**23**:168-173

[8] Institute of Medicine. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: National Academies

[9] LeFevre ML, Bain RP, Ewigman BG, Frigoletto FD, Crane JP, McNellis D.

[1] Martin JA, Hamilton BE,

NCHS Data Brief. 2012;**80**:1-8

[2] Martin JA, Hamilton BE,

2011;**60**:1-70

**References**

2002;**26**:239-249

2002;**52**:671-681

2003;**13**:218-223

1995;**24**:943-948

[31] Lynch L, Berkowitz RL, Stone J, Alvarez M, Lapinski R. Preterm delivery after selective termination in twin pregnancies. Obstetrics and Gynecology. 1996;**87**:366-369

[32] Lee YM, Cleary-Goldman J, Thaker HM, Simpson LL. Antenatal sonographic prediction of twin chorionicity. American Journal of Obstetrics and Gynecology. 2006;**195**:863-867

[33] Finberg HJ. The "twin peak" sign: Reliable evidence of dichorionic twinning. Journal of Ultrasound in Medicine. 1992;**11**:571-577

[34] Reichmann JP. Home uterine activity monitoring: An evidence review of its utility in multiple gestations. The Journal of Reproductive Medicine. 2009;**54**:559-562

[35] Berghella V, Hayes E, Visintine J, Baxter JK. Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews. 2008;(4):CD006843. DOI: 10.1002/14651858.CD006843.pub2

[36] Joffe GM, Jacques D, Bemis-Heys R, Burton R, Skram B, Shelburne P. Impact of the fetal fibronectin assay on admissions for preterm labor. American Journal of Obstetrics and Gynecology. 1999;**180**:581-586

[37] Giles W, Bisits A, Knox M, Madsen G, Smith R. The effect of fetal fibronectin testing on admissions to a tertiary maternal-fetal medicine unit and cost savings. American Journal of Obstetrics and Gynecology. 2000;**182**:439-442

[38] Grobman WA, Welshman EE, Calhoun EA. Does fetal fibronectin use in the diagnosis of preterm labor affect physician behavior and health care costs? A randomized trial. American Journal of Obstetrics and Gynecology. 2004;**191**:235-240

[39] Ness A, Visintine J, Ricci E, Berghella V. Does knowledge of cervical length and fetal fibronectin affect management of women with threatened preterm labor? A randomized trial. American Journal of Obstetrics and Gynecology. 2007;**197**:426.e1-426.e7

[40] Plaut MM, Smith W, Kennedy K. Fetal fibronectin: The impact of a rapid test on the treatment of women with preterm labor symptoms. American Journal of Obstetrics and Gynecology. 2003;**188**:1588-1593 discussion 1593-5

[41] Dor J, Shalev J, Mashiach S, Blankstein J, Serr DM. Elective cervical suture of twin pregnancies diagnosed ultrasonically in the first trimester following induced ovulation. Gynecologic and Obstetric Investigation. 1982;**13**:55-60

[42] Rebarber A, Roman AS, Istwan N, Rhea D, Stanziano G. Prophylactic cerclage in the management of triplet pregnancies. American Journal of Obstetrics and Gynecology. 2005;**193**:1193-1196

[43] Moragianni VA, Aronis KN, Craparo FJ. Biweekly ultrasound assessment of cervical shortening in triplet pregnancies and the effect of cerclage placement. Ultrasound in Obstetrics & Gynecology. 2011;**37**:617-618

[44] Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: Meta-analysis of trials using individual patient-level data. Obstetrics and Gynecology. 2005;**106**:181-189

[45] Roman AS, Saltzman DH, Fox N, Klauser CK, Istwan N, Rhea D, et al. Prophylactic cerclage in the management of twin pregnancies. American Journal of Perinatology. 2013;**30**:751-754

**95**

*Multifetal Gestations*

[46] Crowther CA, Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database of Systematic Reviews. 2010;(7):CD000110. DOI:

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

of preterm labor. American Journal of Obstetrics and Gynecology.

[54] Gabriel R, Harika G, Saniez D, Durot S, Quereux C, Wahl P. Prolonged intravenous ritodrine therapy: A comparison between multiple and singleton pregnancies. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 1994;**57**:65-71

[55] Food and Drug Administration. FDA Drug Safety Communication: New Warnings against Use of Terbutaline to Treat Preterm Labor. Silver Spring (MD): FDA; 2011. Available from: http://www.fda.gov/drugs/drugsafety/ ucm243539.htm [Accessed: 31 January

[56] Liem S, Schuit E, Hegeman M, Bais J, de Boer K, Bloemenkamp K, et al. Cervical pessaries for prevention of preterm birth in women with a multiple pregnancy (ProTWIN): A multicentre, open-label randomised controlled trial.

[57] Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, Thom EA, Spong CY, et al. A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The New England Journal of Medicine.

[58] Norman JE, Mackenzie F, Owen P, Mactier H, Hanretty K, Cooper S, et al. Progesterone for the prevention of preterm birth in twin pregnancy (STOPPIT): A randomised, double-blind, placebo-controlled study and meta-analysis. Lancet.

[59] Combs CA, Garite T, Maurel K, Das A, Porto M. 17-hydroxyprogesterone

caproate for twin pregnancy: A double-blind, randomized clinical trial. Obstetrix Collaborative

Lancet. 2013;**382**:1341-1349

2007;**357**:454-461

2009;**373**:2034-2040

1991;**165**:1401-1404

2014]

10.1002/14651858.CD000110.pub2

[47] Wilkins IA, Lynch L, Mehalek KE, Berkowitz GS, Berkowitz RL. Efficacy and side effects of magnesium sulfate and ritodrine as tocolytic agents. American Journal of Obstetrics and Gynecology. 1988;**159**:685-689

[48] Samol JM, Lambers DS. Magnesium sulfate tocolysis and pulmonary edema: The drug or the vehicle? American Journal of Obstetrics and Gynecology.

[49] Cetrulo CL, Freeman RK. Ritodrine HCL for the prevention of premature labor in twin pregnancies. Acta Geneticae Medicae et Gemellologiae.

[50] O'Leary JA. Prophylactic tocolysis of twins. American Journal of Obstetrics and Gynecology. 1986;**154**:904-905

Verkuyl DA, Waterman R, Ashurst HM. Failure to prevent preterm labour and delivery in twin pregnancy using prophylactic oral salbutamol. British Journal of Obstetrics and Gynaecology.

Pereira L, Lumbiganon P. Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy. Cochrane Database of Systematic Reviews. 2012;(9):CD004733. DOI: 10.1002/14651858.CD004733.pub3

[53] Fletcher SE, Fyfe DA, Case CL, Wiles HB, Upshur JK, Newman RB. Myocardial necrosis in a newborn after long-term maternal subcutaneous terbutaline infusion for suppression

[51] Ashworth MF, Spooner SF,

2005;**192**:1430-1432

1976;**25**:321-324

1990;**97**:878-882

[52] Yamasmit W,

Chaithongwongwatthana S, Tolosa JE, Limpongsanurak S, *Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

*Family Planning and Reproductive Health*

[31] Lynch L, Berkowitz RL, Stone J, Alvarez M, Lapinski R. Preterm delivery [39] Ness A, Visintine J, Ricci E,

2007;**197**:426.e1-426.e7

Berghella V. Does knowledge of cervical length and fetal fibronectin affect management of women with threatened preterm labor? A randomized trial. American

Journal of Obstetrics and Gynecology.

[40] Plaut MM, Smith W, Kennedy K. Fetal fibronectin: The impact of a rapid test on the treatment of women with preterm labor symptoms. American Journal of Obstetrics and Gynecology. 2003;**188**:1588-1593 discussion 1593-5

[41] Dor J, Shalev J, Mashiach S,

suture of twin pregnancies diagnosed ultrasonically in the first trimester following induced ovulation. Gynecologic and Obstetric

Investigation. 1982;**13**:55-60

2005;**193**:1193-1196

2011;**37**:617-618

2013;**30**:751-754

Blankstein J, Serr DM. Elective cervical

[42] Rebarber A, Roman AS, Istwan N, Rhea D, Stanziano G. Prophylactic cerclage in the management of triplet pregnancies. American Journal of Obstetrics and Gynecology.

[43] Moragianni VA, Aronis KN, Craparo FJ. Biweekly ultrasound assessment of cervical shortening in triplet pregnancies and the effect of cerclage placement. Ultrasound in Obstetrics & Gynecology.

[44] Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: Meta-analysis of trials using individual patient-level data. Obstetrics and Gynecology. 2005;**106**:181-189

[45] Roman AS, Saltzman DH, Fox N, Klauser CK, Istwan N,

Rhea D, et al. Prophylactic cerclage in the management of twin pregnancies. American Journal of Perinatology.

after selective termination in twin pregnancies. Obstetrics and Gynecology. 1996;**87**:366-369

[32] Lee YM, Cleary-Goldman J, Thaker HM, Simpson LL. Antenatal sonographic prediction of twin chorionicity. American Journal of Obstetrics and Gynecology.

[33] Finberg HJ. The "twin peak" sign: Reliable evidence of dichorionic twinning. Journal of Ultrasound in

[34] Reichmann JP. Home uterine

activity monitoring: An evidence review of its utility in multiple gestations. The Journal of Reproductive Medicine.

[35] Berghella V, Hayes E, Visintine J, Baxter JK. Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews. 2008;(4):CD006843. DOI: 10.1002/14651858.CD006843.pub2

[36] Joffe GM, Jacques D, Bemis-Heys R, Burton R, Skram B, Shelburne P. Impact

admissions for preterm labor. American Journal of Obstetrics and Gynecology.

Madsen G, Smith R. The effect of fetal fibronectin testing on admissions to a tertiary maternal-fetal medicine unit and cost savings. American Journal of Obstetrics and Gynecology.

[38] Grobman WA, Welshman EE, Calhoun EA. Does fetal fibronectin use in the diagnosis of preterm labor affect physician behavior and health care costs? A randomized trial. American Journal of Obstetrics and Gynecology.

of the fetal fibronectin assay on

[37] Giles W, Bisits A, Knox M,

Medicine. 1992;**11**:571-577

2006;**195**:863-867

2009;**54**:559-562

1999;**180**:581-586

2000;**182**:439-442

2004;**191**:235-240

**94**

[46] Crowther CA, Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database of Systematic Reviews. 2010;(7):CD000110. DOI: 10.1002/14651858.CD000110.pub2

[47] Wilkins IA, Lynch L, Mehalek KE, Berkowitz GS, Berkowitz RL. Efficacy and side effects of magnesium sulfate and ritodrine as tocolytic agents. American Journal of Obstetrics and Gynecology. 1988;**159**:685-689

[48] Samol JM, Lambers DS. Magnesium sulfate tocolysis and pulmonary edema: The drug or the vehicle? American Journal of Obstetrics and Gynecology. 2005;**192**:1430-1432

[49] Cetrulo CL, Freeman RK. Ritodrine HCL for the prevention of premature labor in twin pregnancies. Acta Geneticae Medicae et Gemellologiae. 1976;**25**:321-324

[50] O'Leary JA. Prophylactic tocolysis of twins. American Journal of Obstetrics and Gynecology. 1986;**154**:904-905

[51] Ashworth MF, Spooner SF, Verkuyl DA, Waterman R, Ashurst HM. Failure to prevent preterm labour and delivery in twin pregnancy using prophylactic oral salbutamol. British Journal of Obstetrics and Gynaecology. 1990;**97**:878-882

[52] Yamasmit W,

Chaithongwongwatthana S, Tolosa JE, Limpongsanurak S, Pereira L, Lumbiganon P. Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy. Cochrane Database of Systematic Reviews. 2012;(9):CD004733. DOI: 10.1002/14651858.CD004733.pub3

[53] Fletcher SE, Fyfe DA, Case CL, Wiles HB, Upshur JK, Newman RB. Myocardial necrosis in a newborn after long-term maternal subcutaneous terbutaline infusion for suppression

of preterm labor. American Journal of Obstetrics and Gynecology. 1991;**165**:1401-1404

[54] Gabriel R, Harika G, Saniez D, Durot S, Quereux C, Wahl P. Prolonged intravenous ritodrine therapy: A comparison between multiple and singleton pregnancies. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 1994;**57**:65-71

[55] Food and Drug Administration. FDA Drug Safety Communication: New Warnings against Use of Terbutaline to Treat Preterm Labor. Silver Spring (MD): FDA; 2011. Available from: http://www.fda.gov/drugs/drugsafety/ ucm243539.htm [Accessed: 31 January 2014]

[56] Liem S, Schuit E, Hegeman M, Bais J, de Boer K, Bloemenkamp K, et al. Cervical pessaries for prevention of preterm birth in women with a multiple pregnancy (ProTWIN): A multicentre, open-label randomised controlled trial. Lancet. 2013;**382**:1341-1349

[57] Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, Thom EA, Spong CY, et al. A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The New England Journal of Medicine. 2007;**357**:454-461

[58] Norman JE, Mackenzie F, Owen P, Mactier H, Hanretty K, Cooper S, et al. Progesterone for the prevention of preterm birth in twin pregnancy (STOPPIT): A randomised, double-blind, placebo-controlled study and meta-analysis. Lancet. 2009;**373**:2034-2040

[59] Combs CA, Garite T, Maurel K, Das A, Porto M. 17-hydroxyprogesterone caproate for twin pregnancy: A double-blind, randomized clinical trial. Obstetrix Collaborative

Research Network. American Journal of Obstetrics and Gynecology. 2011;**204**:221.e1-221.e8

[60] Combs CA, Garite T, Maurel K, Das A, Porto M. Failure of 17-hydroxyprogesterone to reduce neonatal morbidity or prolong triplet pregnancy: A double-blind, randomized clinical trial. Obstetrix Collaborative Research Network [published erratum appears in Am J Obstet Gynecol 2011;204:166]. American Journal of Obstetrics and Gynecology. 2010;**203**:248.e1-248.e9

[61] Caritis SN, Rouse DJ, Peaceman AM, Sciscione A, Momirova V, Spong CY, et al. Prevention of preterm birth in triplets using 17 alphahydroxyprogesterone caproate: A randomized controlled trial. Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU). Obstetrics and Gynecology. 2009;**113**:285-292

[62] Durnwald CP, Momirova V, Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, et al. Second trimester cervical length and risk of preterm birth in women with twin gestations treated with 17-alpha hydroxyprogesterone caproate. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The Journal of Maternal-Fetal & Neonatal Medicine. 2010;**23**:1360-1364

[63] Wood S, Ross S, Tang S, Miller L, Sauve R, Brant R. Vaginal progesterone to prevent preterm birth in multiple pregnancy: A randomized controlled trial. Journal of Perinatal Medicine. 2012. DOI: 10.1515/jpm-2012-0057 (Level I)

[64] Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Progesterone and the risk of preterm birth among women with a short cervix. Fetal Medicine Foundation Second

Trimester Screening Group. The New England Journal of Medicine. 2007;**357**:462-469

[65] Romero J, Rebarber A, Saltzman DH, Schwartz R, Peress D, Fox NS. The prediction of recurrent preterm birth in patients on 17-alpha-hydroxyprogesterone caproate using serial fetal fibronectin and cervical length. American Journal of Obstetrics and Gynecology. 2012;**207**:51.e1-51.e5

[66] Senat MV, Porcher R, Winer N, Vayssiere C, Deruelle P, Capelle M, et al. Prevention of preterm delivery by 17 alpha-hydroxyprogesterone caproate in asymptomatic twin pregnancies with a short cervix: A randomized controlled trial. Groupe de Recherche en Obstetrique et Gynecologie. American Journal of Obstetrics and Gynecology. 2013;**208**:194.e1-194.e8

[67] Serra V, Perales A, Meseguer J, Parrilla JJ, Lara C, Bellver J, et al. Increased doses of vaginal progesterone for the prevention of preterm birth in twin pregnancies: A randomised controlled double-blind multicentre trial. BJOG. 2013;**120**:50-57

[68] Haas DM, Quinney SK, Clay JM, Renbarger JL, Hebert MF, Clark S, et al. Nifedipine pharmacokinetics are influenced by CYP3A5 genotype when used as a preterm labor tocolytic. Obstetric-Fetal Pharmacology Research Units Network. American Journal of Perinatology. 2013;**30**:275-281

[69] Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews. 2006;(3):CD004454. DOI: 10.1002/1465 1858.CD004454.pub2

[70] Effect of corticosteroids for fetal maturation on perinatal outcomes. NIH Consens Statement. 1994;**12**(2):1-24

**97**

*Multifetal Gestations*

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

mortality in preterm infants: A metaanalysis. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Obstetrics and

Gynecology. 2009;**114**:354-364

[78] Magnesium sulfate before anticipated preterm birth for neuroprotection. Committee Opinion No. 455. American College of Obstetricians and Gynecologists.

Obstetrics and Gynecology.

Dungan J, Prenger V. Aneuploidy in twin gestations: When is maternal age advanced? Obstetrics and Gynecology.

[80] Rodis JF, Egan JF, Craffey A, Ciarleglio L, Greenstein RM,

abnormalities in twin gestations. Obstetrics and Gynecology.

[81] Garchet-Beaudron A, Dreux S, Leporrier N, Oury JF, Muller F. Secondtrimester Down syndrome maternal serum marker screening: A prospective study of 11 040 twin pregnancies. ABA Study Group, Clinical Study Group. Prenatal Diagnosis. 2008;**28**:1105-1109

[82] Bush MC, Malone FD. Down syndrome screening in twins. Clinics in Perinatology. 2005;**32**:373-386 vi

[83] Chasen ST, Perni SC, Kalish RB, Chervenak FA. First trimester risk assessment for trisomies 21 and 18 in twin pregnancy. American Journal of Obstetrics and Gynecology.

[84] Sebire NJ, Snijders RJ, Hughes K, Sepulveda W, Nicolaides KH. Screening for trisomy 21 in twin pregnancies by maternal age and fetal nuchal

translucency thickness at 10-14 weeks of gestation. British Journal of Obstetrics and Gynaecology. 1996;**103**:999-1003

2007;**197**:374.e1-374.e3

Scorza WE. Calculated risk of chromosomal

[79] Meyers C, Adam R,

2010;**115**:669-671

1997;**89**:248-251

1990;**76**:1037-1041

[71] Antenatal corticosteroid therapy for fetal maturation. Committee Opinion No. 677. American College of Obstetricians and Gynecologists.

[72] Crowther CA, Hiller JE, Doyle LW, Haslam RR. Effect of magnesium sulfate given for neuroprotection before preterm birth: A randomized controlled trial. Australasian Collaborative Trial of Magnesium Sulphate (ACTOMg SO4) Collaborative Group. JAMA.

Obstetrics and Gynecology.

2016;**128**:e187-e194

2003;**290**:2669-2676

[73] Marret S, Marpeau L, Zupan-Simunek V, Eurin D, Leveque C, Hellot MF, et al. Magnesium sulphate given before very-preterm birth to protect infant brain: The randomised controlled PREMAG trial. PREMAG trial group. BJOG. 2007;**114**:310-318

[74] Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, et al. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. The New England Journal of

Medicine. 2008;**359**:895-905

[75] Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic Reviews. 2009;(1): CD004661. DOI: 10.1002/14651858.

[76] Conde-Agudelo A, Romero R. Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeks' gestation: A systematic review and metaanalysis. American Journal of Obstetrics and Gynecology. 2009;**200**:595-609

[77] Costantine MM, Weiner SJ. Effects of antenatal exposure to magnesium sulfate on neuroprotection and

CD004661.pub3

#### *Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

*Family Planning and Reproductive Health*

Journal of Obstetrics and Gynecology.

Trimester Screening Group. The New England Journal of Medicine.

Saltzman DH, Schwartz R, Peress D, Fox NS. The prediction of recurrent

Journal of Obstetrics and Gynecology.

[66] Senat MV, Porcher R, Winer N, Vayssiere C, Deruelle P, Capelle M, et al. Prevention of preterm delivery by 17 alpha-hydroxyprogesterone caproate in asymptomatic twin pregnancies with a short cervix: A randomized controlled trial. Groupe de Recherche en Obstetrique et Gynecologie. American Journal of Obstetrics and Gynecology.

[67] Serra V, Perales A, Meseguer J, Parrilla JJ, Lara C, Bellver J, et al. Increased doses of vaginal progesterone for the prevention of preterm birth in twin pregnancies: A randomised controlled double-blind multicentre

[68] Haas DM, Quinney SK, Clay JM, Renbarger JL, Hebert MF, Clark S, et al. Nifedipine pharmacokinetics are influenced by CYP3A5 genotype when used as a preterm labor tocolytic. Obstetric-Fetal Pharmacology Research Units Network. American Journal of Perinatology. 2013;**30**:275-281

[69] Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews.

2006;(3):CD004454. DOI: 10.1002/1465

[70] Effect of corticosteroids for fetal maturation on perinatal outcomes. NIH Consens Statement. 1994;**12**(2):1-24

1858.CD004454.pub2

2007;**357**:462-469

2012;**207**:51.e1-51.e5

2013;**208**:194.e1-194.e8

trial. BJOG. 2013;**120**:50-57

[65] Romero J, Rebarber A,

preterm birth in patients on 17-alpha-hydroxyprogesterone caproate using serial fetal fibronectin and cervical length. American

Maurel K, Das A, Porto M. Failure of 17-hydroxyprogesterone to reduce neonatal morbidity or prolong triplet pregnancy: A double-blind, randomized clinical trial. Obstetrix Collaborative Research Network [published erratum appears in Am J Obstet Gynecol 2011;204:166]. American Journal of Obstetrics and Gynecology.

[61] Caritis SN, Rouse DJ, Peaceman AM, Sciscione A, Momirova V, Spong CY, et al. Prevention of preterm birth

Research Network. American

2011;**204**:221.e1-221.e8

[60] Combs CA, Garite T,

2010;**203**:248.e1-248.e9

in triplets using 17 alpha-

hydroxyprogesterone caproate: A randomized controlled trial. Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU). Obstetrics and

Gynecology. 2009;**113**:285-292

[62] Durnwald CP, Momirova V, Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, et al. Second trimester cervical length and risk of preterm birth in women with twin gestations treated with 17-alpha hydroxyprogesterone caproate. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The Journal of Maternal-Fetal & Neonatal Medicine.

[63] Wood S, Ross S, Tang S, Miller L, Sauve R, Brant R. Vaginal progesterone to prevent preterm birth in multiple pregnancy: A randomized controlled trial. Journal of Perinatal Medicine. 2012. DOI: 10.1515/jpm-2012-0057 (Level I)

[64] Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Progesterone

and the risk of preterm birth among women with a short cervix. Fetal Medicine Foundation Second

2010;**23**:1360-1364

**96**

[71] Antenatal corticosteroid therapy for fetal maturation. Committee Opinion No. 677. American College of Obstetricians and Gynecologists. Obstetrics and Gynecology. 2016;**128**:e187-e194

[72] Crowther CA, Hiller JE, Doyle LW, Haslam RR. Effect of magnesium sulfate given for neuroprotection before preterm birth: A randomized controlled trial. Australasian Collaborative Trial of Magnesium Sulphate (ACTOMg SO4) Collaborative Group. JAMA. 2003;**290**:2669-2676

[73] Marret S, Marpeau L, Zupan-Simunek V, Eurin D, Leveque C, Hellot MF, et al. Magnesium sulphate given before very-preterm birth to protect infant brain: The randomised controlled PREMAG trial. PREMAG trial group. BJOG. 2007;**114**:310-318

[74] Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, et al. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. The New England Journal of Medicine. 2008;**359**:895-905

[75] Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic Reviews. 2009;(1): CD004661. DOI: 10.1002/14651858. CD004661.pub3

[76] Conde-Agudelo A, Romero R. Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeks' gestation: A systematic review and metaanalysis. American Journal of Obstetrics and Gynecology. 2009;**200**:595-609

[77] Costantine MM, Weiner SJ. Effects of antenatal exposure to magnesium sulfate on neuroprotection and

mortality in preterm infants: A metaanalysis. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Obstetrics and Gynecology. 2009;**114**:354-364

[78] Magnesium sulfate before anticipated preterm birth for neuroprotection. Committee Opinion No. 455. American College of Obstetricians and Gynecologists. Obstetrics and Gynecology. 2010;**115**:669-671

[79] Meyers C, Adam R, Dungan J, Prenger V. Aneuploidy in twin gestations: When is maternal age advanced? Obstetrics and Gynecology. 1997;**89**:248-251

[80] Rodis JF, Egan JF, Craffey A, Ciarleglio L, Greenstein RM, Scorza WE. Calculated risk of chromosomal abnormalities in twin gestations. Obstetrics and Gynecology. 1990;**76**:1037-1041

[81] Garchet-Beaudron A, Dreux S, Leporrier N, Oury JF, Muller F. Secondtrimester Down syndrome maternal serum marker screening: A prospective study of 11 040 twin pregnancies. ABA Study Group, Clinical Study Group. Prenatal Diagnosis. 2008;**28**:1105-1109

[82] Bush MC, Malone FD. Down syndrome screening in twins. Clinics in Perinatology. 2005;**32**:373-386 vi

[83] Chasen ST, Perni SC, Kalish RB, Chervenak FA. First trimester risk assessment for trisomies 21 and 18 in twin pregnancy. American Journal of Obstetrics and Gynecology. 2007;**197**:374.e1-374.e3

[84] Sebire NJ, Snijders RJ, Hughes K, Sepulveda W, Nicolaides KH. Screening for trisomy 21 in twin pregnancies by maternal age and fetal nuchal translucency thickness at 10-14 weeks of gestation. British Journal of Obstetrics and Gynaecology. 1996;**103**:999-1003

[85] Sepulveda W, Wong AE, Casasbuenas A. Nuchal translucency and nasal bone in first-trimester ultrasound screening for aneuploidy in multiple pregnancies. Ultrasound in Obstetrics & Gynecology. 2009;**33**:152-156

[86] Sebire NJ, D'Ercole C, Hughes K, Carvalho M, Nicolaides KH. Increased nuchal translucency thickness at 10-14 weeks of gestation as a predictor of severe twin-to-twin transfusion syndrome. Ultrasound in Obstetrics & Gynecology. 1997;**10**:86-89

[87] Noninvasive prenatal testing for fetal aneuploidy. Committee Opinion No. 545. American College of Obstetricians and Gynecologists. Obstetrics and Gynecology. 2012;**120**:1532-1534

[88] Agarwal K, Alfirevic Z. Pregnancy loss after chorionic villus sampling and genetic amniocentesis in twin pregnancies: A systematic review. Ultrasound in Obstetrics & Gynecology. 2012;**40**:128-134

[89] Simonazzi G, Curti A, Farina A, Pilu G, Bovicelli L, Rizzo N. Amniocentesis and chorionic villus sampling in twin gestations: Which is the best sampling technique? American Journal of Obstetrics and Gynecology. 2010;**202**:365.e1-365.e5

[90] Cahill AG, Macones GA, Stamilio DM, Dicke JM, Crane JP, Odibo AO. Pregnancy loss rate after mid-trimester amniocentesis in twin pregnancies. American Journal of Obstetrics and Gynecology. 2009;**200**:257.e1-257.e6

[91] Eddleman KA, Stone JL, Lynch L, Berkowitz RL. Chorionic villus sampling before multifetal pregnancy reduction. American Journal of Obstetrics and Gynecology. 2000;**183**:1078-1081

[92] Talbot GT, Goldstein RF, Nesbitt T, Johnson JL, Kay HH. Is size discordancy an indication for delivery of preterm twins? American Journal of Obstetrics and Gynecology. 1997;**177**:1050-1054

[93] Breathnach FM, McAuliffe FM, Geary M, Daly S, Higgins JR, Dornan J, et al. Definition of intertwin birth weight discordance. Obstetrics & Gynecology. 2011;**118**(1):94-103. DOI: 10.1097/ AOG.0b013e31821fd208

[94] Lopriore E, Slaghekke F, Vandenbussche FP, Middeldorp JM, Walther FJ, Oepkes D. Cerebral injury in monochorionic twins with selective intrauterine growth restriction and/ or birthweight discordance. American Journal of Obstetrics and Gynecology. 2008;**199**:628.e1-628.e5

[95] Appleton C, Pinto L, Centeno M, Clode N, Cardoso C, Graca LM. Near term twin pregnancy: Clinical relevance of weight discordance at birth. Journal of Perinatal Medicine. 2007;**35**:62-66

[96] Cohen SB, Elizur SE, Goldenberg M, Beiner M, Novikov I, Mashiach S, et al. Outcome of twin pregnancies with extreme weight discordancy. American Journal of Perinatology. 2001;**18**:427-432

[97] Kilic M, Aygun C, Kaynar-Tuncel E, Kucukoduk S. Does birth weight discordance in preterm twins affect neonatal outcome? Journal of Perinatology. 2006;**26**:268-272

[98] Yinon Y, Mazkereth R, Rosentzweig N, Jarus-Hakak A, Schiff E, Simchen MJ. Growth restriction as a determinant of outcome in preterm discordant twins. Obstetrics and Gynecology. 2005;**105**:80-84

[99] Odibo AO, McDonald RE, Stamilio DM, Ural SH, Macones GA. Perinatal outcomes in growth-restricted twins compared with age-matched growth-restricted singletons.

**99**

*Multifetal Gestations*

2005;**22**:269-273

2002;**186**:77-83

Update. 1998;**4**:177-183

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

et al. Brain damage to the survivor within 30 min of co-twin demise in monochorionic twins. Fetal Diagnosis

D'Alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated latepreterm and early-term birth. Obstetrics and Gynecology. 2011;**118**:323-333

[111] Giles W, Bisits A, O'Callaghan S, Gill A. The Doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. DAMP Study Group. BJOG.

[112] Twin-twin transfusion syndrome. Society for Maternal-Fetal Medicine [published erratum appears in Am J Obstet Gynecol 2013;208:392]. American Journal of Obstetrics and

and Therapy. 2005;**20**:91-95

[109] Spong CY, Mercer BM,

[110] Alexander GR, Kogan M, Martin J, Papiernik E. What are the fetal growth patterns of singletons, twins, and triplets in the United States? Clinical Obstetrics and Gynecology.

1998;**41**:114-125

2003;**110**:593-597

Gynecology. 2013;**208**:3-18

[113] Sueters M, Middeldorp JM, Lopriore E, Oepkes D, Kanhai HH, Vandenbussche FP. Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms. Ultrasound in Obstetrics &

Gynecology. 2006;**28**:659-664

StudyGroupConsensusViews

February 2014]

MultiplePregnancy.pdf [Accessed: 05

[114] Royal College of Obstetricians and Gynaecologists. Consensus Views Arising from the 50th Study Group: Multiple Pregnancy. London: RCOG; 2006. Available from: http://www.rcog. org.uk/files/rcog-corp/uploaded-files/

[100] Landy HJ, Keith LG. The vanishing twin: A review. Human Reproduction

American Journal of Perinatology.

[101] Dickey RP, Taylor SN, Lu PY, Sartor BM, Storment JM, Rye PH, et al. Spontaneous reduction of multiple pregnancy: Incidence and effect on outcome. American Journal of Obstetrics and Gynecology.

[102] D'Alton ME, Simpson LL. Syndromes in twins. Seminars in Perinatology. 1995;**19**:375-386

[103] Lee YM, Wylie BJ, Simpson LL, D'Alton ME. Twin chorionicity and the risk of stillbirth [published erratum appears in Obstet Gynecol 2008;111:1217]. Obstetrics and Gynecology. 2008;**111**:301-308

[104] Morikawa M, Yamada T, Yamada T, Sato S, Cho K, Minakami H. Prospective

risk of stillbirth: Monochorionic diamniotic twins vs. dichorionic twins. Journal of Perinatal Medicine.

[105] Danon D, Sekar R, Hack KE, Fisk NM. Increased stillbirth in uncomplicated monochorionic twin pregnancies: A systematic review and meta-analysis. Obstetrics and Gynecology. 2013;**121**:1318-1326

[106] Hillman SC, Morris RK, Kilby MD. Co-twin prognosis after single fetal death: A systematic review and meta-analysis. Obstetrics and Gynecology. 2011;**118**:928-940

[107] Ong SS, Zamora J, Khan KS, Kilby MD. Prognosis for the co-twin

[108] Karageyim Karsidag AY, Kars B, Dansuk R, Api O, Unal O, Turan MC,

following single-twin death: A systematic review. BJOG.

2006;**113**:992-998

2012;**40**:245-249

*Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

American Journal of Perinatology. 2005;**22**:269-273

*Family Planning and Reproductive Health*

Casasbuenas A. Nuchal translucency and nasal bone in first-trimester ultrasound screening for aneuploidy in multiple pregnancies. Ultrasound

an indication for delivery of preterm twins? American Journal of Obstetrics and Gynecology. 1997;**177**:1050-1054

[93] Breathnach FM, McAuliffe FM, Geary M, Daly S, Higgins JR, Dornan J, et al. Definition of intertwin birth weight discordance.

Obstetrics & Gynecology. 2011;**118**(1):94-103. DOI: 10.1097/

[94] Lopriore E, Slaghekke F, Vandenbussche FP, Middeldorp JM, Walther FJ, Oepkes D. Cerebral injury in monochorionic twins with selective intrauterine growth restriction and/ or birthweight discordance. American Journal of Obstetrics and Gynecology.

AOG.0b013e31821fd208

2008;**199**:628.e1-628.e5

[96] Cohen SB, Elizur SE,

[95] Appleton C, Pinto L, Centeno M, Clode N, Cardoso C, Graca LM. Near term twin pregnancy: Clinical relevance of weight discordance at birth. Journal of Perinatal Medicine. 2007;**35**:62-66

Goldenberg M, Beiner M, Novikov I, Mashiach S, et al. Outcome of twin pregnancies with extreme weight discordancy. American Journal of Perinatology. 2001;**18**:427-432

[97] Kilic M, Aygun C, Kaynar-Tuncel E,

Rosentzweig N, Jarus-Hakak A, Schiff E, Simchen MJ. Growth restriction as a determinant of outcome in preterm discordant twins. Obstetrics and Gynecology. 2005;**105**:80-84

Kucukoduk S. Does birth weight discordance in preterm twins affect neonatal outcome? Journal of Perinatology. 2006;**26**:268-272

[98] Yinon Y, Mazkereth R,

[99] Odibo AO, McDonald RE, Stamilio DM, Ural SH, Macones GA. Perinatal outcomes in growth-restricted twins compared with age-matched growth-restricted singletons.

[86] Sebire NJ, D'Ercole C, Hughes K, Carvalho M, Nicolaides KH. Increased nuchal translucency thickness at 10-14 weeks of gestation as a predictor of severe twin-to-twin transfusion syndrome. Ultrasound in Obstetrics &

[85] Sepulveda W, Wong AE,

in Obstetrics & Gynecology.

Gynecology. 1997;**10**:86-89

Obstetrics and Gynecology.

[89] Simonazzi G, Curti A, Farina A, Pilu G, Bovicelli L,

2010;**202**:365.e1-365.e5

2009;**200**:257.e1-257.e6

[90] Cahill AG, Macones GA, Stamilio DM, Dicke JM, Crane JP, Odibo AO. Pregnancy loss rate after mid-trimester amniocentesis in twin pregnancies. American

2012;**120**:1532-1534

2012;**40**:128-134

[87] Noninvasive prenatal testing for fetal aneuploidy. Committee Opinion No. 545. American College of Obstetricians and Gynecologists.

[88] Agarwal K, Alfirevic Z. Pregnancy loss after chorionic villus sampling and genetic amniocentesis in twin pregnancies: A systematic review. Ultrasound in Obstetrics & Gynecology.

Rizzo N. Amniocentesis and chorionic villus sampling in twin gestations: Which is the best sampling technique? American Journal of Obstetrics and Gynecology.

Journal of Obstetrics and Gynecology.

[91] Eddleman KA, Stone JL, Lynch L, Berkowitz RL. Chorionic villus sampling before multifetal pregnancy reduction. American Journal of Obstetrics and Gynecology. 2000;**183**:1078-1081

[92] Talbot GT, Goldstein RF, Nesbitt T, Johnson JL, Kay HH. Is size discordancy

2009;**33**:152-156

**98**

[100] Landy HJ, Keith LG. The vanishing twin: A review. Human Reproduction Update. 1998;**4**:177-183

[101] Dickey RP, Taylor SN, Lu PY, Sartor BM, Storment JM, Rye PH, et al. Spontaneous reduction of multiple pregnancy: Incidence and effect on outcome. American Journal of Obstetrics and Gynecology. 2002;**186**:77-83

[102] D'Alton ME, Simpson LL. Syndromes in twins. Seminars in Perinatology. 1995;**19**:375-386

[103] Lee YM, Wylie BJ, Simpson LL, D'Alton ME. Twin chorionicity and the risk of stillbirth [published erratum appears in Obstet Gynecol 2008;111:1217]. Obstetrics and Gynecology. 2008;**111**:301-308

[104] Morikawa M, Yamada T, Yamada T, Sato S, Cho K, Minakami H. Prospective risk of stillbirth: Monochorionic diamniotic twins vs. dichorionic twins. Journal of Perinatal Medicine. 2012;**40**:245-249

[105] Danon D, Sekar R, Hack KE, Fisk NM. Increased stillbirth in uncomplicated monochorionic twin pregnancies: A systematic review and meta-analysis. Obstetrics and Gynecology. 2013;**121**:1318-1326

[106] Hillman SC, Morris RK, Kilby MD. Co-twin prognosis after single fetal death: A systematic review and meta-analysis. Obstetrics and Gynecology. 2011;**118**:928-940

[107] Ong SS, Zamora J, Khan KS, Kilby MD. Prognosis for the co-twin following single-twin death: A systematic review. BJOG. 2006;**113**:992-998

[108] Karageyim Karsidag AY, Kars B, Dansuk R, Api O, Unal O, Turan MC, et al. Brain damage to the survivor within 30 min of co-twin demise in monochorionic twins. Fetal Diagnosis and Therapy. 2005;**20**:91-95

[109] Spong CY, Mercer BM, D'Alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated latepreterm and early-term birth. Obstetrics and Gynecology. 2011;**118**:323-333

[110] Alexander GR, Kogan M, Martin J, Papiernik E. What are the fetal growth patterns of singletons, twins, and triplets in the United States? Clinical Obstetrics and Gynecology. 1998;**41**:114-125

[111] Giles W, Bisits A, O'Callaghan S, Gill A. The Doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. DAMP Study Group. BJOG. 2003;**110**:593-597

[112] Twin-twin transfusion syndrome. Society for Maternal-Fetal Medicine [published erratum appears in Am J Obstet Gynecol 2013;208:392]. American Journal of Obstetrics and Gynecology. 2013;**208**:3-18

[113] Sueters M, Middeldorp JM, Lopriore E, Oepkes D, Kanhai HH, Vandenbussche FP. Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms. Ultrasound in Obstetrics & Gynecology. 2006;**28**:659-664

[114] Royal College of Obstetricians and Gynaecologists. Consensus Views Arising from the 50th Study Group: Multiple Pregnancy. London: RCOG; 2006. Available from: http://www.rcog. org.uk/files/rcog-corp/uploaded-files/ StudyGroupConsensusViews MultiplePregnancy.pdf [Accessed: 05 February 2014]

[115] Lewi L, Gucciardo L, Van Mieghem T, de Koninck P, Beck V, Medek H, et al. Monochorionic diamniotic twin pregnancies: Natural history and risk stratification. Fetal Diagnosis and Therapy. 2010;**27**:121-133

[116] Stamilio DM, Fraser WD, Moore TR. Twin-twin transfusion syndrome: An ethics-based and evidence-based argument for clinical research. American Journal of Obstetrics and Gynecology. 2010;**203**:3-16

[117] Slotnick RN, Ortega JE. Monoamniotic twinning and zona manipulation: A survey of U.S. IVF centers correlating zona manipulation procedures and high-risk twinning frequency. Journal of Assisted Reproduction and Genetics. 1996;**13**:381-385

[118] Baxi LV, Walsh CA. Monoamniotic twins in contemporary practice: A single-center study of perinatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2010;**23**:506-510

[119] DeFalco LM, Sciscione AC, Megerian G, Tolosa J, Macones G, O'Shea A, et al. Inpatient versus outpatient management of monoamniotic twins and outcomes. American Journal of Perinatology. 2006;**23**:205-211

[120] Ezra Y, Shveiky D, Ophir E, Nadjari M, Eisenberg VH, Samueloff A, et al. Intensive management and early delivery reduce antenatal mortality in monoamniotic twin pregnancies. Acta Obstetricia et Gynecologica Scandinavica. 2005;**84**:432-435

[121] Sogaard K, Skibsted L, Brocks V. Acardiac twins: Pathophysiology, diagnosis, outcome and treatment. Six cases and review of the literature. Fetal Diagnosis and Therapy. 1999;**14**:53-59

[122] van Gemert MJ, Umur A, van den Wijngaard JP, VanBavel E,

Vandenbussche FP, Nikkels PG. Increasing cardiac output and decreasing oxygenation sequence in pump twins of acardiac twin pregnancies. Physics in Medicine and Biology. 2005;**50**:N33-N42

[123] Mutchinick OM, Luna-Munoz L, Amar E, Bakker MK, Clementi M, Cocchi G, et al. Conjoined twins: A worldwide collaborative epidemiological study of the International Clearinghouse for Birth Defects Surveillance and Research. American Journal of Medical Genetics. Part C, Seminars in Medical Genetics. 2011;**157C**:274-287

[124] Spitz L, Kiely EM. Conjoined twins. JAMA. 2003;**289**:1307-1310

[125] Mackenzie TC, Crombleholme TM, Johnson MP, Schnaufer L, Flake AW, Hedrick HL, et al. The natural history of prenatally diagnosed conjoined twins. Journal of Pediatric Surgery. 2002;**37**:303-309

[126] Refuerzo JS, Momirova V, Peaceman AM, Sciscione A, Rouse DJ, Caritis SN, et al. Neonatal outcomes in twin pregnancies delivered moderately preterm, late preterm, and term. American Journal of Perinatology. 2010;**27**:537-542

[127] Cheung YB, Yip P, Karlberg J. Mortality of twins and singletons by gestational age: A varying-coefficient approach. American Journal of Epidemiology. 2000;**152**:1107-1116

[128] Crowther CA. Caesarean delivery for the second twin. Cochrane Database of Systematic Reviews. 2011;(12):CD000047. DOI: 10.1002/14651858.CD000047.pub2

[129] Barrett JF, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. Twin Birth Study Collaborative Group [published erratum appears

**101**

*Multifetal Gestations*

2013;**369**:1295-1305

2010;**115**:221-222

1998;**179**:942-945

*DOI: http://dx.doi.org/10.5772/intechopen.92050*

[137] Myles T. Vaginal birth of twins after a previous Cesarean section. The Journal of Maternal-Fetal Medicine.

[138] Miller DA, Mullin P, Hou D, Paul RH. Vaginal birth after cesarean section in twin gestation. American Journal of Obstetrics and Gynecology.

[139] Francois K, Ortiz J, Harris C, Foley MR, Elliott JP. Is peripartum hysterectomy more common in multiple gestations? Obstetrics and Gynecology.

[140] Quintero RA, Morales WJ, Allen MH, et al. Staging of twin-twin transfusion syndrome. Journal of Perinatology. 1999;**19**:550-555

2001;**10**:171-174

1996;**175**:194-198

2005;**105**:1369-1372

in N Engl J Med 2013;369:2364]. The New England Journal of Medicine.

[130] D'Alton ME. Delivery of the second twin: Revisiting the age-old dilemma. Obstetrics and Gynecology.

[131] Grobman WA, Peaceman AM, Haney EI, Silver RK, MacGregor SN. Neonatal outcomes in triplet gestations

Journal of Obstetrics and Gynecology.

[132] Alamia V Jr, Royek AB, Jaekle RK, Meyer BA. Preliminary experience with a prospective protocol for planned vaginal delivery of triplet gestations. American Journal of Obstetrics and Gynecology. 1998;**179**:1133-1135

[133] Wildschut HI, van Roosmalen J, van Leeuwen E, Keirse MJ. Planned abdominal compared with planned vaginal birth in triplet pregnancies. British Journal of Obstetrics and Gynaecology. 1995;**102**:292-296

[134] Sansregret A, Bujold E, Gauthier RJ. Twin delivery after a previous caesarean: A twelve-year experience. Journal of Obstetrics and Gynaecology Canada. 2003;**25**:294-298

[135] Cahill A, Stamilio DM, Pare E, Peipert JP, Stevens EJ, Nelson DB, et al. Vaginal birth after cesarean (VBAC) attempt in twin pregnancies: Is it safe? American Journal of Obstetrics and Gynecology. 2005;**193**:1050-1055

[136] Varner MW, Thom E, Spong CY, Landon MB, Leveno KJ, Rouse DJ, et al. Trial of labor after one previous cesarean delivery for multifetal gestation. National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Obstetrics and

Gynecology. 2007;**110**:814-819

after a trial of labor. American

#### *Multifetal Gestations DOI: http://dx.doi.org/10.5772/intechopen.92050*

in N Engl J Med 2013;369:2364]. The New England Journal of Medicine. 2013;**369**:1295-1305

*Family Planning and Reproductive Health*

Vandenbussche FP, Nikkels PG. Increasing cardiac output and decreasing oxygenation sequence in pump twins of acardiac twin pregnancies. Physics in Medicine and

[123] Mutchinick OM, Luna-Munoz L, Amar E, Bakker MK, Clementi M, Cocchi G, et al. Conjoined twins: A worldwide collaborative epidemiological study of the International Clearinghouse for Birth Defects Surveillance and Research. American Journal of Medical Genetics. Part C, Seminars in Medical

Biology. 2005;**50**:N33-N42

Genetics. 2011;**157C**:274-287

2002;**37**:303-309

2010;**27**:537-542

[124] Spitz L, Kiely EM. Conjoined twins. JAMA. 2003;**289**:1307-1310

[126] Refuerzo JS, Momirova V,

Peaceman AM, Sciscione A, Rouse DJ, Caritis SN, et al. Neonatal outcomes in twin pregnancies delivered moderately preterm, late preterm, and term. American Journal of Perinatology.

[127] Cheung YB, Yip P, Karlberg J. Mortality of twins and singletons by gestational age: A varying-coefficient approach. American Journal of Epidemiology. 2000;**152**:1107-1116

[128] Crowther CA. Caesarean delivery for the second twin. Cochrane Database of Systematic Reviews. 2011;(12):CD000047. DOI: 10.1002/14651858.CD000047.pub2

Twin Birth Study Collaborative Group [published erratum appears

[129] Barrett JF, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy.

[125] Mackenzie TC, Crombleholme TM, Johnson MP, Schnaufer L, Flake AW, Hedrick HL, et al. The natural history of prenatally diagnosed conjoined twins. Journal of Pediatric Surgery.

[115] Lewi L, Gucciardo L, Van Mieghem T, de Koninck P, Beck V, Medek H, et al. Monochorionic diamniotic twin pregnancies: Natural history and risk stratification. Fetal Diagnosis and

Therapy. 2010;**27**:121-133

2010;**203**:3-16

1996;**13**:381-385

[116] Stamilio DM, Fraser WD, Moore TR. Twin-twin transfusion syndrome: An ethics-based and evidence-based argument for clinical research. American Journal of Obstetrics and Gynecology.

[117] Slotnick RN, Ortega JE. Monoamniotic twinning and zona manipulation: A survey of U.S. IVF centers correlating zona manipulation procedures and high-risk twinning frequency. Journal of Assisted Reproduction and Genetics.

[118] Baxi LV, Walsh CA. Monoamniotic twins in contemporary practice: A single-center study of perinatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2010;**23**:506-510

outpatient management of monoamniotic twins and outcomes. American Journal of Perinatology. 2006;**23**:205-211

[119] DeFalco LM, Sciscione AC, Megerian G, Tolosa J, Macones G, O'Shea A, et al. Inpatient versus

[120] Ezra Y, Shveiky D, Ophir E, Nadjari M, Eisenberg VH, Samueloff A, et al. Intensive management and early delivery reduce antenatal mortality in monoamniotic twin pregnancies. Acta Obstetricia et Gynecologica Scandinavica. 2005;**84**:432-435

[121] Sogaard K, Skibsted L, Brocks V. Acardiac twins:

Therapy. 1999;**14**:53-59

Pathophysiology, diagnosis, outcome and treatment. Six cases and review of the literature. Fetal Diagnosis and

[122] van Gemert MJ, Umur A, van den Wijngaard JP, VanBavel E,

**100**

[130] D'Alton ME. Delivery of the second twin: Revisiting the age-old dilemma. Obstetrics and Gynecology. 2010;**115**:221-222

[131] Grobman WA, Peaceman AM, Haney EI, Silver RK, MacGregor SN. Neonatal outcomes in triplet gestations after a trial of labor. American Journal of Obstetrics and Gynecology. 1998;**179**:942-945

[132] Alamia V Jr, Royek AB, Jaekle RK, Meyer BA. Preliminary experience with a prospective protocol for planned vaginal delivery of triplet gestations. American Journal of Obstetrics and Gynecology. 1998;**179**:1133-1135

[133] Wildschut HI, van Roosmalen J, van Leeuwen E, Keirse MJ. Planned abdominal compared with planned vaginal birth in triplet pregnancies. British Journal of Obstetrics and Gynaecology. 1995;**102**:292-296

[134] Sansregret A, Bujold E, Gauthier RJ. Twin delivery after a previous caesarean: A twelve-year experience. Journal of Obstetrics and Gynaecology Canada. 2003;**25**:294-298

[135] Cahill A, Stamilio DM, Pare E, Peipert JP, Stevens EJ, Nelson DB, et al. Vaginal birth after cesarean (VBAC) attempt in twin pregnancies: Is it safe? American Journal of Obstetrics and Gynecology. 2005;**193**:1050-1055

[136] Varner MW, Thom E, Spong CY, Landon MB, Leveno KJ, Rouse DJ, et al. Trial of labor after one previous cesarean delivery for multifetal gestation. National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Obstetrics and Gynecology. 2007;**110**:814-819

[137] Myles T. Vaginal birth of twins after a previous Cesarean section. The Journal of Maternal-Fetal Medicine. 2001;**10**:171-174

[138] Miller DA, Mullin P, Hou D, Paul RH. Vaginal birth after cesarean section in twin gestation. American Journal of Obstetrics and Gynecology. 1996;**175**:194-198

[139] Francois K, Ortiz J, Harris C, Foley MR, Elliott JP. Is peripartum hysterectomy more common in multiple gestations? Obstetrics and Gynecology. 2005;**105**:1369-1372

[140] Quintero RA, Morales WJ, Allen MH, et al. Staging of twin-twin transfusion syndrome. Journal of Perinatology. 1999;**19**:550-555

**103**

Section 5

Case Report
