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Emily Greenlee, MD

• Clinical Assistant Professor of Ophthalmology
• Department of Ophthalmology
• Roy J. and Lucille A. Carver College of Medicine
• University of Iowa
• Iowa City, Iowa

Encephalocoele anxiety zoning out buy discount luvox 100 mg line, (Q01) A cephalocoele is a defect in the bony skull through which meninges and brain substance may protrude anxiety symptoms jumpy order discount luvox. It is the result of a defect of neural tube closure during the 6th week of gestation anxiety 24 hour helpline cheap luvox 100 mg with amex. The location of the defect is mid occipital in 75% of cases anxiety 2020 episodes 50mg luvox fast delivery, fronto-ethmoidal in 13% and parietal in 12%. Spina Bifida, (Q05)15 Spina bifida is a general term used to describe a neural tube defect of the spine in which part of the meninges or spinal cord or both protrudes through an opening in the vertebral column. Posterior defects of neural tube closure are among the most common fetal abnormalities. In closed spina bifida the bony defect of the posterior vertebral arches, the herniated meninges and neural tissue are covered by a layer of skin. The commonest associated abnormality was Arnold-Chiari Malformation, (Q070), consisting of downward displacement of the cerebellar tonsils through the foramen magnum. The codes in the Q05 section describe both the site of the defect and if hydrocephalus is present or not. When coding spina bifida with Arnold Chiari malformation it is practice to use the best possible code for spina bifida within Q05 and add the code for Arnold Chiari, (Q070). It is important to note that the prevalence of microcephaly varies considerably with annual fluctuations a likely consequence of the rarity of this condition. The shortcomings of many surveillance programmes coupled with the rarity of microcephaly mean that changes in prevalence, potentially due to Zika virus, could be missed. Atresia of Foramina of Magendie & Luschka, (Q031) Dandy Walker malformation is defined by hydrocephalus and partial or complete absence of the cerebellar vermis with a posterior fossa cyst that opens directly into the 4th ventricle. However, cases have been described in which atresia has not been present and it is considered that the anomaly is a due to a more complex developmental error. Ultrasound scan reveals a cystic mass in the posterior fossa and an abnormally shaped cerebellum with some dilatation of the lateral ventricles. Ventriculomegaly, (Q038) & Unspecified Congenital Hydrocephalus, (Q039) Congenital ventriculomegaly may not be due to fluid circulation abnormalities, but should be reported if the size of the ventricles is 15 mm or more. For less severe prenatally detected ventriculomegaly (10-14 mm) it is recommended to follow the case until further imaging and a final diagnosis has been found postnatally. Ultrasound detection of a defect in the corpus callosum is difficult and requires a very detailed examination. Reduction Anomaly of the Cerebellum, (Q0432) Classification systems for malformations of the cerebellum are varied and are constantly being revised as greater understanding of the underlying genetics and embryology of the disorders is uncovered. The prognosis of this developmental disorder is highly dependent on the underlying disorder. It is generally considered to be an encepholoclastic lesion originating in the third trimester because of severe ischaemic insult(s) due to widespread vascular occlusion, infections or prolonged severe hydrocephalus. The prognosis is grave and with prenatal diagnosis pregnancy termination is an option. Congenital heart defects are those gross structural abnormalities of the heart or intra-thoracic vessels that are of actual or potential functional significance. They are one of the most important causes of infant morbidity and mortality and continue to constitute an important cause of disability and death in adult life. There is a large body of evidence emerging on the genetic and non-genetic risk factors for congenital heart disease. Other determinants, (some of which are potentially modifiable), include maternal diabetes, therapeutic and non-therapeutic drug exposure and lifestyle characteristics. The most severe forms of congenital heart disease should be identifiable on prenatal ultrasound by 24 weeks? gestation. The classic four-chamber view? will diagnose the majority but not all of these abnormalities. Additional views including visualization of both left and right outflow tracts are recommended to improve diagnostic ascertainment. This detection rate must be viewed with some caution because the cardiac lesions may not have been the defining feature for cases where they are classified in the secondary position. Looking only at the 22 cases where a primary diagnosis of severe cardiac anomaly was made, a prenatal detection rate of 50% is calculated, (n=11), which is disappointing. Genetic disorders and teratogens have been implicated in aetiology, (including maternal diabetes). Other associated cardiac anomalies include mitral atresia, aortic arch anomalies and almost complete absence of the interventricular septum creating a single ventricle. Up to 30% of cases are associated with chromosome 22q11 deletion, (Di George), syndrome. The three-vessel view will be abnormal because the pulmonary artery lies below the aortic arch. The right atrium is connected to the morphological left ventricle which gives rise to the pulmonary trunk. Instead a common atrioventricular valve bridges the defect and there is loss of the normal differential insertion seen at the crux on the four chamber view. Atrioventricular septal defects are one of the most common forms of heart disease seen in prenatal life. The scan appearance is one of a single valve opening into both ventricular chambers. Prognosis depends on the presence of other abnormalities but as an isolated lesion long-term prognosis following correctional surgery is generally good. This type of defect is often associated with extra cardiac defects and chromosomal disorders, particularly Trisomy 21. However prenatally only three features are reliably seen: right ventricular hypertrophy may not be evident until the latter stages of pregnancy or indeed early neonatal life. This is done by ensuring that there is continuity between the left ventricle and aortic outflow. The abnormality may also be suspected when there is difficulty identifying the right outflow tract owing to pulmonary stenosis or atresia. Extra-cardiac defects, chromosomal anomalies and genetic conditions, (particularly 22q11. Aortic Valve Atresia or Stenosis, (Q224) this is a narrowing at the level of the aortic valve. It is rarely associated with extracardiac or genetic causes and is an evolving lesion, progressive during pregnancy. Approximately 10% of cases are associated with a chromosomal abnormality, usually Trisomy 13, Trisomy 18 or Turner syndrome. In severe cases the four-chamber view is already abnormal in the second trimester. The aorta is extremely hypoplastic and its origin and course are difficult to define. The mitral valve fails to open and there is no demonstrable flow from the left atrium to left ventricle on colour flow Doppler. Compensatory dilatation of the right ventricle and pulmonary trunk may be present. The most reliable way to assess the aortic arch is in the transverse view in the upper thorax. However, visualization of the aortic arch in longitudinal section is not a usual component of the routine prenatal ultrasound scan. In this view the aortic arch is smaller than normal and smaller than the arterial duct. There may be disproportion between the left and right ventricles and between the aortic arch and pulmonary trunk. However, this is not a reliable diagnostic feature as a slight discrepancy in size between left and right ventricle will be seen in a healthy third trimester fetus. Coarctation of the aorta is accompanied by extra-cardiac anomalies in 25% of cases. Typical anomalies include those whose embryonic development coincides with the timing and location of aortic arch development and include upper gastrointestinal tract anomalies such as oesophageal atresia and diaphragmatic defect. A total of six cases of coarctation of the aorta were diagnosed in 2015-2016, the majority, (n=4), had the abnormality coded in the primary position.

The mortality associated with untreated hydrocephalus is alarmingly high anxiety frequent urination discount 100mg luvox with amex, ranging from to 20? 87% anxiety chat room purchase luvox amex. At a health sys tems level anxiety 9 year old daughter buy luvox 100 mg fast delivery, the diagnostic process and in-hospital costs associated with hydrocephalus manage ment results in a high financial burden anxiety symptoms heart discount luvox online visa. Inpatient care of pediatric hydrocephalus patients alone a decade ago was reported to cost approximately $2 billion per year in the United States alone. When stratified by age groups, the global prevalence of hydrocephalus is 88/100,000 in the pediatric population, 11/ 100,000 in adults and 175/100,000 in the elderly and potentially >400/100,000 in those >80 years of age. The prevalence of hydrocephalus is significantly higher in Africa and South America when compared to other continents. From congenital birth defect registries, the incidence of hydrocephalus was 81/100,000 births. This would not identify postnatal causes of hydrocephalus which would be expected to result in an incidence of hydrocephalus that is higher by one year of age. Pooled mean prevalence/100,000 of hydrocephalus in elderly population stratified by continent. Although folate fortification is mandatory in many countries and numerous reviews have supported the use of folate as a prenatal or continuing supplement[77?83], the effect of folate supplementation on hydrocephalus (in humans) has not been well characterized. However, given that approximately 80% of infants with spinal tube defects develop hydrocephalus[64, 65], one would expect a decrease in hydrocephalus, along with the reported decrease in spina bifida incidence with supplementation. While we did not find any difference in hydrocephalus incidence with or without mandatory folate fortification, we would caution against making any major inferences from these findings. In order to accurately inform patients, families and policy makers worldwide on the effect folate fortification on hydrocephalus, further studies are required. Nevertheless, this study may be leveraged to stimulate interest in future studies designed with a focused objective on the effect of mandatory folate fortification on the epidemiology of hydrocephalus. The reported prevalence of hydrocephalus in adults in this study demonstrates a U-shaped pattern across the age continuum, with an 8-fold decline from pediatrics to adults and a subse quent 17-fold rise to the elderly. It is important to note that hydrocephalus is a chronic disease and the survival of pediatric hydrocephalus patients with surgical treatment is high. Therefore, prevalence by definition should include all patients with the diagno sis in the adult population, which also include patients who received treatment during child hood. Prevalence (per 100,000) of hydrocephalus in the pediatric and elderly populations combined and shaded by continent from which the paper used in the meta-analysis was published. The bimodal pattern in estimates may also be partly attributed to compen sated/arrested hydrocephalus?, that has been hypothesized as a quiescence of congenital hydrocephalus during the pediatric-adult age transition, which later decompensates to resur face in the elderly age. This manuscript presents information regarding the global population-based epidemiology of hydrocephalus to better inform the healthcare community, policy makers and the public. There are however, specific nuances of hydrocephalus epidemiology outside of this structured analysis that also require attention. As previously mentioned, hydrocephalus is a heteroge neous disease that emanates from, as well as complicates a broad range of intracranial condi tions such as trauma, infection, hemorrhage, tumors and genetic syndromes. Within these distinct subgroups of hydrocephalus etiologies, there is significant variation in the incidence and prevalence of hydrocephalus that is not easily captured by the methodology used for our prevalence evaluation. However, the diagnosis of hydrocephalus in these diagnoses signifi cantly impact patient care and is also of critical importance to the healthcare provider. Aneurysmal subarachnoid hemorrhage is a risk factor for developing both acute obstructive hydrocephalus and chronic communicating hydrocephalus. Our search strategy identified 9 papers reporting on the incidence of treated hydrocephalus in this population, which ranged from 10%[94] to 65%. Bekelis et al document the expected difference in shunting rates after endovascular coiling of 10,607 aneurysms, 6,056 of which were unruptured. The difference in mean annual incidence between high vs low/medium income (B) and between countries with and without mandatory folate fortification (C) are depicted. Post-infectious hydrocephalus is a major global health problem, with high prevalence in Africa and Asia. Patients with commu nity-acquired Escherichia coli and Streptococcus pneumoniae meningitis who develop post infectious hydrocephalus have a mortality risk of almost 60. Limitations and future directions One of the drawbacks to combining these studies stems from the lack of consensus on a unify ing definition or classification of hydrocephalus. While a working description of hydrocepha lus has been proposed[1], the existing differing classification and definition of the disease, and the lack of standardization in epidemiological reporting practices precludes a robust analysis. The varying definition of hydrocephalus and methods of screening and diagnosis contributed to between study heterogeneity. However, despite this heterogeneity, these are the best possible estimates regarding the global epidemiology of hydrocephalus, which now sets the stage for future studies to unravel the vital questions surrounding the various subtypes of secondary hydrocephalus. The possibility that our calculated prevalence of hydrocephalus may change if those excluded papers were added to the data analysis is small given that 21/23 of these papers dealt with congenital or infantile hydrocephalus and our analysis was based upon reports of almost 29 million pediatric patients. A majority of the papers included in the prevalence and incidence analyses, respectively emanate from medium to high-income countries. Therefore, there is a possibility that the epidemiological data presented in this manuscript may be an underestimation due to under-notification in low income coun tries. However, these are not felt to be significant issues and we are confident in the precision of the prevalence and incidence of hydrocephalus in the pediatric population presented in this paper. The precision of the prevalence estimates for the elderly and more so the adult data were limited by the small number of high-quality population-based epidemiology papers that were available. However, hydrocephalus in these groups is also of critical importance and future studies may focus on addressing those. Conclusions Hydrocephalus is a common neurologic condition that has significant implications for the patient and society. Previously, a lack of consistent epidemiological data has negatively affected the awareness of the disease and promoted incommensurate allocation of resources for the care of patients and research. We were able to estimate the global prevalence of hydrocephalus in pediatric, adult, and elderly populations and determine the global incidence of hydrocepha lus. While folate fortification was not associated with the incidence of hydrocephalus, the inci dence of hydrocephalus was higher in low-medium income compared to high-income countries. The expected increase in the elderly with aging demography, underscores the importance of healthcare resource allocation and further study of the burden of hydrocephalus. Citations in non-English or French language that were excluded during abstract reviews. R script for generating world map shaded by continent with the prevalence of hydrocephalus in the pediatric and elderly populations[66]. We wish to acknowledge the membership of Neurological Health Charities Canada and the Public Health Agency of Canada for their contribution to the success of this initiative. Pringsheim, Nathalie Jette, Brendan Cord Lethebe, Mark Lowerison, Jarred Dronyk, Mark G. Isaacs, Jay Riva-Cambrin, Nathalie Jette, Brendan Cord Lethebe, Mark Lowerison, Mark G. Epidemiology of Idiopathic Normal Pressure Hydrocephalus: A Systematic Review of the Literature. Global hydrocephalus epi demiology and incidence: systematic review and meta-analysis. The prevalence of low back pain in adults: a methodological review of the lit erature. Epidemiology and direct economic impact of hydrocephalus: a community based study. Five-year incidence of surgery for idio pathic normal pressure hydrocephalus in Norway. Prevalence of idiopathic normal-pressure hydrocephalus in the elderly population of a Japanese rural community. Nationwide hospital-based survey of idiopathic normal pressure hydrocephalus in Japan: Epidemiological and clinical characteristics. Prevalence of Possible Idiopathic Normal Pressure Hydrocephalus in Japan: the Osaki-Tajiri Project. Hydrocephalic children presenting to a Malaysian community-based university hospital over an 8-year period. The prevalence of neurologi cal disorders in Saudi children: a community-based study. Congenital malformations in newborns in a teaching hospital in eastern Saudi Arabia. Risk of selected structural abnormalities in infants after increased nuchal translucency measurement. Cancer risk in children and ado lescents with birth defects: a population-based cohort study.

Other more traditional methods are the Temperature and Billing method anxiety fear purchase generic luvox line, mostly used to measure fertility periods and recently supported by online family planning apps anxiety symptoms teenagers buy luvox 100 mg free shipping. First generation: included norethisterone and norethindrone acetate containing pills b anxiety 4 hereford bull cheap generic luvox uk. During the lifetime it is necessary to look at the right match anxiety symptoms 4 weeks purchase luvox 50mg overnight delivery, which is based on personal preferences and medical contra indications, but also on the reasons of women (and partners) for not wanting to become pregnant. It is important to understand the reasons women (and men/partners) have for not wanting to become pregnant. Some of them would like to delay their pregnancy, while others already have the number of children they want (limit births). There are also women who already have one or more children and they want to wait a few years to become pregnant again, they prefer to space their births. Per region the reasons for not wanting to become pregnant differ widely among women as can be seen in the following graphic. Another contraceptive that has been around since 1842 is the diaphragm (Harvey et all, 2004). More modern contraceptive methods like the oral contraception pill were firstly introduced in the 1960s. In the 1950s large scale clinical trials were conducted and the pill was tested on Puerto Rican and Haitian women. The pill appeared to be 100% effective, although some serious side-effects were present but ignored in the beginning. In the Netherlands the pill was introduced in 1964 and in four years four out of 10 Dutch women between the ages of 21 and 34 had used it (Ketting, 1982). With the introduction of the pill, it was the first time that sexuality and reproduction were disconnected and women could enjoy sexuality without worrying about pregnancy. In most countries the pill was only available for married women, but this was still revolutionary. It empowered women to take control over their own bodies, of their sexuality and their desire to have or not to have a child. After the introduction, discussions started if the contraception pill would contribute to a greater freedom and sexual empowerment of women or attribute to more coercion and pleasure for men (Andere Tijden, 2002). In 1967 the controversy around the pill took a new dimension when African-American activists claimed that by providing the pill in poor, minority neighbourhoods, genocide was committed (Blakemore, 2018; Vargas, 2017). The Pearl Index indicates the number of pregnancies that will occur, on average, when a specific method is used by 100 women in one year. The reliability of contraceptive methods is based on 2 indicators, the method itself and the rate of it being used correctly. In the table below you can see the percentages of the perfect use (when the method is always used correctly) and the percentages of the typical use (in reality). If for example 100 sexually active couples will use no contraceptive method for one year, about 85% of the women will get pregnant, therefor the Pearl index is 85%. The Pearl Index is often criticized, as it does not consider that contraceptive failure rates typically decline with continued use. Therefore, a Pearl Index determined by a study of new and short-term users of a method will likely be higher than in a study of long-term users. Demographic factors are also not considered, although they influence method adherence and, in turn, efficacy. Because of variations in study design, study populations, and data collection and analyses, rates of contraceptive failure reported in clinical trials are difficult to interpret and compare. Due to many different studies and interpretations, different Pearl Indexes are available. Long acting reversible contraception and sterilization are associated with the lowest pregnancy rates. Oral contraceptives, the patch and vaginal ring, are also associated with a very low pregnancy rate if they are used consistently and 6 correctly. Other methods of contraception, including diaphragms, cervical caps, sponges, male and female condoms, spermicides, periodic abstinence and withdrawal are associated with actual pregnancy rates that are much higher than perfect use rates. Actual effectiveness is also influenced by frequency of intercourse, age, and regularity of menstrual cycles. Pregnancies are less likely in women who are older, have infrequent sexual intercourse, and have irregular menstrual cycles. Contraceptives reduce the number of unintended and unplanned pregnancies and therefore help prevent pregnancy related deaths and infant deaths. International bodies repeatedly call on states to ensure women have access to contraceptives. Reproductive rights are defined as: Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. Under International Human Rights Law, states have an obligation to provide women with access to a full range of contraceptives and information on the methods and it stipulates that women should have access to female-controlled contraceptives (Shalev, 1998). In the Programme of Action it is clearly affirmed that reproductive and sexual health is protected within the human rights already recognized by both national and international law. Moreover, the complex link between population, growth and gender equality was recognized. During the 1995 World Conference in Beijing it was highlighted, among other issues, that women and men have the right to equal access to education and health care and equal treatment. Although a lot of progress has been made considering reproductive health and rights, much more can and needs to be improved. Education in general has a key role in preventing early and unintended pregnancies. The birth rate declines in most countries were contraceptives are available, affordable and accepted. The core state obligations in connection to the right to health, is to ensure the availability, accessibility and acceptability of contraceptives. Furthermore, International Human Rights law requires health-care facilities, commodities and services to be accessible to everyone without discrimination. This includes physical and economic accessibility as well as access to information. All healthcare facilities, commodities and services must also adhere to acceptability and therefore be respectful of medical ethics, the culture of individuals, minorities and communities and be sensitive to gender and life cycle requirements. Although in most countries a wide range of contraceptive methods are available and provided by most reproductive health services, differences may exist in availability of methods between urban and rural or private and governmental hospitals and health centers. Accessibility is mainly dependent on the cultural, economic and political contexts of individuals and countries. Particularly young people, poorer segments of populations or unmarried people have limited access to contraception. Young and unmarried people in many communities are not allowed or expected to have sexual relationships before marriage. Therefore, prescriptions might not be given without parental consent or health services are not youth friendly. Dutch case: Availability of contraception in the Netherlands In the Netherlands male condoms are widely available at pharmacies, drugstores, supermarkets and vending machines in bars, online or in entertainment venues in the Netherlands. Since a couple of years the female condom is available but only online or at the condom shop and drugstores. The emergency pills (Norlevo since 2005 and Ella One since 2015) are available at the pharmacy without prescription. Since 2015 midwifes may also prescribe contraception and in 2018 they may place and inserts all kind of contraception. They inform adolescents about a wide range of contraception methods, but not all Sense services can deliver or insert all contraption methods. Once a prescription is obtained all modern contraceptives are obtainable at the drugstore. For the pill no repeat prescription is needed once an initial prescription has been obtained.

For this analysis anxiety grounding techniques discount luvox online american express, age is treated as a categorical variable anxiety yelling order luvox with amex, thus the 5-year age groups 15-19 anxiety symptoms 10 year old boy buy luvox in united states online, 20-24 anxiety symptoms even on medication purchase cheap luvox on line, 25-29, 30-34, 35-39, 40-44 and 45-49 are used. Type of marital union distinguishes between formal union and cohabitation (live-in arrangement or consensual union). Highest educational attainment refers to the highest level of schooling completed by the respondent and is categorized into no education, elementary, high school, and college or higher. Wealth quintile is an aggregate measure of the socioeconomic status of the household where the woman resides. Work status of the woman is a bivariate measure on whether or not she has done any work in the past seven days. Some basic characteristics of the husband/partner were also identified as possible factors that could affect the contraceptive method used. Age difference between the woman and her husband/partner was grouped into three categories: husband/partner is older by at least four years, husband/partner is of the same age or older by up to three years, and woman is older than husband/partner. Fertility-related characteristics of the women were also identified as factors associated with contraceptive method use. Women with correct knowledge refers to those who answered that a woman is more likely to get pregnant halfway between two menstrual cycles, while women with incorrect knowledge refers to those who mentioned otherwise or responded that they do not know when the fertile period is. It should be noted that the variable representing print media for the year 2003 is a composite variable from three questions inquiring about family planning exposure through newspaper or magazine, poster, or leaflet or brochure separately, whereas all these were included as one question in the 2008 and 2013 surveys. The 2013 survey also asked about the Internet as a source of family planning messages but, although the Internet has become an important media form, these data are not included in the analysis because there are no comparable data from the two earlier surveys. Survey year is included as a factor in analyzing use of traditional contraceptive methods among Filipino women over time. Methods of Analysis Cross-tabulations and tests of proportions were employed in comparing the characteristics of women using traditional and modern contraceptive methods and in ascertaining statistical significance in the differences. Multinomial logistic regression was used to predict the determinants of current use of rhythm (periodic abstinence) or withdrawal (both traditional methods) relative to current use of modern contraceptive method (base group). Trends in contraceptive use: 2003-2013 Table 1 shows the contraceptive method mix among the sample of currently married, fecund, and sexually active current users for the three survey years and the percentage point differences for three time periods: 2003-2008, 2008-2013, and 2003-2013. Modern contraceptive methods comprise the largest share of contraceptive prevalence across all survey periods. However, the use of traditional methods also accounts for nearly one-third of contraceptive use from 2003 to 2013. Percent distribution of currently married women age 15-49 who are using a contraceptive method by type of contraceptive method currently used and percentage point difference, Philippines 2003, 2008, and 2013 Percentage Percentage point difference Overall Contraceptive method 2003 2008 2013 2003-2008 2008-2013 2003-2013 Traditional method 31. The pill is the most widely used contraceptive method in all survey years and recorded the largest increase in both 5 year survey intervals, with an overall increase of 7. Next to the pill, the most preferred method is withdrawal; its prevalence increased from 17% in 2003 to 22% in 2013?an increase of 5 percentage points over the 10-year period, with the largest share of the increase occurring between 2008 and 2013. In contrast, use of rhythm decreased in 11 prevalence, from 13% in 2003 to 12% five years later and further to 9% in 2013. Male sterilization remains negligible, at a level even lower than that of folkloric methods. Distribution of women who are current contraceptive users: 2003-2013 the succeeding analyses are on a total of 11,815 cases. As mentioned in the data section, women who reported use of folkloric methods were excluded because of the small number of cases in all survey years (98). The distribution of fecund, currently married (formally or consensually), sexually active contraceptive users has not changed substantially from 2003 to 2013 (Table 2). Most of these women were in the peak of childbearing age 25-34, while a few were teenagers. Over the survey period, however, the percentage of cohabiting women more than doubled, from 9% in 2003 to 22% in 2013. Percent distribution of currently married women age 15-49 who are currently using a contraceptive method, by sociodemographic characteristics, Philippines 2003, 2008, and 2013 Survey year 2003 2008 2013 Sociodemographic Number of Number of Number of characteristic % women % women % women Age 15-19 1. There was also an increase between 2003 and 2008 in the percentage of women working, but the percentage then declined slightly, from 55% in 2008 to 54% in 2013. Between 2003 and 2013, the percentage of women in rural areas using contraception increased, while it decreased slightly among followers of the Catholic religion. Filipino couples are mostly in the same age group, although, on average, men are older than their partners by three years. Nonetheless, in 2013, 41% of women had husbands who were at least four years older, slightly more than the percentage of women whose husbands were the same age. High school seems to be the terminal level for most, since the percentage with elementary education and the percentage with college education or more has declined over time. Across the three survey years, the percentage of women with one or two children increased by 6 percentage points, to 47%, while the average number of children remained at three (Table 3). Percent distribution of currently married women age 15-49 who are currently using a contraceptive method, by fertility-related characteristics, Philippines 2003, 2008, and 2013 Survey year 2003 2008 2013 Fertility-related Number Number Number characteristic % of women % of women % of women No. Print media such as newspapers, magazines, posters, leaflets, or brochures are not as popular in 2013 as 10 years earlier, although the change could be due to a measurement issue since the question was asked differently in the earlier survey (see Key Variables and Measures). In 2013, one of every six women reported the Internet as a source of family planning information (data not shown). Association between type of contraceptive method used and socio-demographic and fertility-related characteristics the succeeding bivariate and multivariate analyses were based on pooled data for women currently using a contraceptive method. Generally, the characteristics of these women have not changed significantly over the three survey periods. Additionally, separate analyses were made for rhythm and withdrawal because of the divergent temporal patterns that these methods show in the trend analysis. Table 4 compares the socio-demographic and fertility-related characteristics of current users of rhythm, withdrawal, and modern methods. Rhythm and withdrawal users are significantly different in all characteristics with the exception of religion, age difference between the woman and her husband/partner, and family planning exposure on television. More importantly, examination of the characteristics of traditional and modern contraceptive method users reveals interesting findings. Considering characteristics 18 of the husband, the use of rhythm is more common among women whose husbands are at least age 40 and women whose husbands are college-educated. As expected, proportionately more women with correct knowledge of the fertile period use the rhythm method compared with users of either withdrawal or modern contraceptive methods. A comparison of users of withdrawal versus users of modern contraceptive methods reveals different patterns than for users of rhythm versus modern contraceptive methods. A higher proportion of withdrawal users than modern contraceptive method users is found among women age 15-29, but the pattern reverses at age 30-44, when modern contraceptive methods become more prevalent. However, only the differences in the use of withdrawal relative to modern contraceptives methods in ages 15-19, 20-24, and 35-39 are statistically significant. Women who reported use of withdrawal tend to be cohabiting, with a high school education, not working, rural, Catholic, married to a husband/partner age 20-39, and older than their husband/partner. Compared with modern contraceptive method users, users of withdrawal are also more likely to have fewer children (0-2), want additional children, and not to have had exposure to family planning messages on radio or print media in the past few months. Determinants of use of traditional contraceptive methods Tables 5 and 6 present results from the multinomial logistic regression on the use of rhythm and withdrawal compared with modern contraceptive methods by socio-demographic and fertility related characteristics. As an initial step towards modeling estimation, explanatory variables were tested for multicollinearity. Because the analysis is based on pooled data of three survey years, time (with survey year as proxy) was incorporated as an explanatory variable in the regression models. Model 1 presents bivariate associations between survey year and the type of contraceptive method used (unadjusted model). The only difference between the two 19 models is that marital union is not statistically significant in Model 2 although the coefficients remained the same. Comparing Model 1 and Model 2, survey year is significantly associated with rhythm use in both models (Table 5). This supports the finding that, over time, rhythm use has been declining in the Philippines. The statistical significance of survey year persisted even when the other background characteristics were incorporated, with relative risk ratios even higher in Model 2 than in Model 1.

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