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2013 than it did the previous year -- and markedly lower rates in nearly all regions when compared to a decade ago. See the Data Sources and Updates Calendar for a detailed list of the data resources used for indicator measures on Virginia Performs. Cover Virginia's Plan First is a Medicaid program that covers the costs of family planning and birth control for eligible women and men in Virginia. South Africa's experience in the fertility transition is among the most advanced in sub-Saharan Africa. With Africans making up 77% of the population, their high incidence and severity of poverty amongst them ensures that they account for 95% of the poverty gap, with the remaining 3% largely accounted for the poverty among Coloureds with the 1% each shared by the Asians and Whites, respectively as shown in Figure III. The differences in poverty by race also contribute to the distribution of poverty by location since the racial groups were unevenly distributed in the country. Thus, among all the four major racial groups in South Africa a decline of fertility has been observed from as early as the 1960s. For South Africa as a whole, fertility was high and stable between 1950 and 1970, estimated at an average of 6 to 7 children per woman. Whites experienced a long and sustained fertility decline from the end of the 19th century until attaining below-replacement fertility by 1989, with a TFR of 1,9 (Chimere-Dan, O, 1993).
However despite this dramatic decline in fertility the majority of African population, especially women still lives in poverty. The introduction of the Population and Development Programme (PDP) in 1984 aimed explicitly at lowering the national population growth rate because the country's resources (especially water) would not sustain the prevailing high rate of population growth. It must also be said, while it fell short of its original objectives, the programme substantially expanded family planning services. Thus ironically, while South Africa's family planning program was conceived and implemented by a minority white government intent on slowing the growth of the majority African population and the African communities resisted this approach. Most of these women were the only breadwinners and in this sense they were forced to adopt contraceptives.
Furthermore, many rural African women were without husbands for long periods, since the latter served as migrant labourers in cities. In the South African context, marriage seems to have lost its value as determinant of fertility.
Although there is a general decline in fertility, teenage pregnancies are still a major concern as illustrated by Table 1. The high rate of teenage pregnancies has far reaching consequences, especially for the Africans and coloureds that are the poorest and most disadvantaged groups in the country. On the other hand, getting pregnant in African communities does not necessarily mean a loss of educational opportunities.
Nevertheless, teenage pregnancies remain one of our major population concerns, which affect mostly communities in the Western Cape, Gauteng and Kwazulu-Natal. It has been argued that a higher fertility rate among unmarried and single mothers is a rational response on the part of women, especially Africans and coloureds, to oppressive and disempowering patriarchal economic, social and cultural systems. A dominant issue in especially the African fertility pattern in South Africa is that of male responsibility in reproductive decision making and health as well as in childbearing and rearing.
Marriage appears to have lost its role as the exclusive domain for socially legitimate childbearing in South Africa.
Because of South Africa's past history of widely accessible family planning services and health services that are well established relative to the situation in the rest of sub-Saharan Africa, the low fertility rate can also be explained by the high use of contraception. Of the different methods used by sexually active women, 30% comprise injectable contraceptives, 13% the pill and 12% female sterilisation.
The comparison of contraceptive use by racial group depicted in Figure V shows clearly that there was a definite increase in contraceptive prevalence amongst all groups except the white population, which, at about 80%, had in any case reached saturation level. Contraceptive preference has changed dramatically: some women are more likely to use contraceptives than others and the type of contraceptives used differ. However, fertility control is far from ideal in South Africa, as evidenced by the fact that about 50% of currently married women have an unmet need for family planning. Younger South Africa women prefer spacing their children, as compared to older women, who prefer limiting the number of births (Du Plessis, 1996). With the increase in prevalence of HIV-infected women and the risks that the continuation of their pregnancies hold for themselves and their children, the number of women seeking abortion could increase considerably.
Patient information: See related handout on pregnancy loss, written by the authors of this article. Conception, early pregnancy loss, and time to clinical pregnancy: a population-based prospective study. The diagnosis and reproductive outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum.
Effectiveness of cervical cerclage for a sonographically shortened cervix: a systematic review and meta-analysis. International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome: report of an international workshop. Prevention of recurrent miscarriage for women with antiphospholipid antibody syndrome or lupus anticoagulant. Overall, there were 7,335 reported teen pregnancies in Virginia in 2013 -- or an average of 27.8 per 1,000 females aged 15 to 19. Family planning is more than just birth control; it includes regular check-ups and screening services that help to protect reproductive health. South Africa displays demographic regimes that are typical of both developed and developing worlds.
At the same time, among Africans, the group comprising nearly all the country's poor, the pattern of much higher poverty in rural areas and the concentration of poverty in the former homelands and some of the provinces still holds. Figure IV shows that the swiftest decline occurred among the coloureds, followed by Africans. It dropped to an average of 4 to 5 children per woman in the period 1980 to 1995 (United Nations, 95).
Asian fertility also declined steadily, from a TFR of about 6 in the 1950s to 2,7 in the late 1980s.

The question that we, however, need to ask is, "How did this fertility transition came about"? Ironically, the African population was either being denied access to well water-resourced arable land, or being removed and relocated to poor water-resourced land.
By the end of the decade about 61.2 percent of women ages 15-49 (including about half African married women) were using some form of contraceptive (See Figure V).
It must, however, made clear that many African women adopted family planning despite the political agenda of the programme.
This can be seen in the context that African women assumed management of their fertility because they found themselves increasingly in precarious circumstances.
In most populations, fertility is directly related to marriage; married women generally have more children than unmarried women of the same age. This can be seen, firstly, from the small and insignificant difference between marital and non-marital fertility of African women in South Africa: in 1996, the average TFR for African women who were never married or who were cohabiting was 3,9, while that of those who were married was 4,3 (Chimere-Dan, 1999). The 1998 SADHS found that 35% of all teenagers had been pregnant or had a child by the age of 19 years. When a school-going girl falls pregnant, she may be forced to leave school, but often only for the rest of the academic year.
Among Africans and to some extent coloureds, marriage is far from being an early and universal social institution. Women have to take on the burden of caring for children and often also of earning the means to do so.
Overall non-marital fertility has been declining more than its marital counterpart in South Africa both on the national level and across the major population groups in the country (Mencarani, 1999).
Whites, who make the least use of public family planning services, choose from a wider range of contraceptive methods. Unmet need for family planning is inversely related to level of education: the percentage of women with no formal education who have an unmet need for family planning is six times higher than the percentage of women at the highest level of education who show such a need.
The general trend by age reveals that younger African, coloured and white women tend to view all their pregnancies as too closely spaced, while older women feel that only some of their births are closely spaced. Before the introduction of legal abortion, the termination of unwanted pregnancies often led to increased risk of death and complications arising from unsafe abortions. At this stage it is unclear what effect legalised abortion will have on the total fertility rate, although literature in this regard suggests that, in countries where legal abortions are common, low fertility is generally associated with a high combined prevalence of abortion and contraceptive use.
Fetal abnormalities, including chromosomal problems, and maternal anatomic factors, immunologic factors, infection, and thrombophilia should be considered; however, a cause-and-effect relationship may be difficult to establish.
Pregnancy loss is considered a miscarriage when it occurs before 20 weeks' gestation; after this time it is considered a stillbirth. Ideally, this work-up should be done during preconception counseling.The history should include symptoms and signs of pregnancy loss, chronic maternal medical conditions that may contribute to pregnancy loss, family history that suggests genetic problems, medication use as an indication of underlying illness, environmental exposures, substance abuse, trauma, and obstetric history.
A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The fertility trends among population groups in South Africa shows the same patterns as that of poverty. Coloured fertility declined remarkably rapidly from 6,5 in the late 1960s to about 3 by the late 1980s. Despite the aim to lower the African population the government at the same time was encouraging an increase in the white population through immigration. Thus the minority population owned, or was systematically taking ownership of most of the well water-resourced land in the country. Many factors - cultural, political and social - converged to deprive African women of financial and familial security.
Many of these migrant husbands simply stopped sending money home or earned too little to be able to afford doing so. Traditionally, births to unmarried women were not accepted in most societies, thus women began bearing children after marriage and continued throughout her reproductive lifetime as long as they remained married.
Secondly, it can be seen from the high rate of teenage pregnancies, mainly to unmarried girls. This represents a very high level of teenage fertility and is a serious source of concern to the government, communities and researchers.
The father of the child seldom acknowledges or takes responsibility for the financial, emotional and practical support of the child.
So high a value is placed on schooling and post-school training, that pregnancy is not allowed to jeopardize it. This intensive control of non-marital fertility appears to be the dominant force in the fertility transition in South Africa. Three-quarters of all women interviewed indicated that they had used a contraceptive method at some stage during their lives, while 61% of sexually active women reported that they were currently using contraception - see Figure V. The very low prevalence of traditional methods (0,7%) is highly significant, as modern methods of contraception are more effective in preventing pregnancy. Africans and coloureds, which constitute the bulk of clients of organised public family planning services, tend to predominately use the contraceptive injection (35% and 27% respectively). This indicates the extent to which unplanned and mistimed pregnancies occur among young women in South Africa.
A thorough history and physical examination should include inquiries about previous pregnancy loss. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The African component which is the poorest with regard to per capita income has the highest fertility rate, while the White population which has the highest per capita income has the lowest fertility rate as explained below. African fertility is estimated to have decreased from a high of 6,8 to a low of about 3,9 between the mid-1950s and the early 1990s. The programme consequently came under much pressure, both for its ideological focus and the inadequacy of its services. These circumstances compelled them to curtail childbearing and to practice family planning, with or without the consent of their husbands or partners.

This, together with the landlessness and joblessness of the homeland system, forced many African women to make their own decisions about family maintenance and reproduction.
In Africa, marriage used to be almost universal and marital fertility was high while non-marital fertility was very low. Teenage pregnancies are more prevalent among coloured and African girls particularly those with little or no education. The mother often leaves school, thus ending her opportunities for personal development, making her vulnerable to poverty, exploitative sexual relationships and violence as well as low self-esteem. Teenage pregnancies among Africans and coloureds do not seem to be perceived in the same negative light as in the case of whites and Asians. High levels of male migration from rural to urban mining areas have affected lower marriage rates among Africans. The decline in non-marital total fertility is more likely to be driven by contraceptive use.
The national average level of current contraceptive use is higher in urban areas at 66% than in rural areas at 52,7%.
At 98,8%of all current contraceptive usage, the use of modern methods is very high compared to that in other sub-Saharan countries. This raises questions about information sharing and the widening of reproductive choices, as well as the issue of women's control over their own bodies and their sexuality.
This further emphasises the fact that the majority of South African women have not yet achieved satisfactory control over their reproduction. The gap between stated fertility preferences and observed fertility levels further illustrate the constraints on women's autonomy in decision-making regarding reproduction.
While poverty is not confined to any one racial group in South Africa, it is concentrated among Africans in particularly.
Although it continues declining, African fertility is still substantially higher than that of the other racial groups. By mid-1980s the programme's management had distanced itself from the demographic intent of the Population Development Programme (PDP). The high use of contraceptive injection indicates that many women are not free to discuss reproductive issues, including contraceptive use, with their husbands or partners. The modern family planning programme introduced by the white apartheid regime in the early seventies, assured that their need for fertility control was met.
The proportion of teenage girls who had experienced a pregnancy grew from 2,4% to 35,1% with each additional year of age, as shown in the third column of Table 1. This high use of modern contraception indicates that South African women generally have good access to family planning services and that they generally trust modern contraceptive methods to achieve their goals of either spacing or limiting the number of children they intend to have. Addressing the unmet need for family planning entails not merely greater access to contraceptive services, but also the enhancement of the status of women through education and employment as well as changes in social structures that influence female autonomy. In this regard, the SADHS revealed that in most cases the ideal number of children a woman wanted was lower than the living number of children she actually had. If a maternal medical illness appears to have contributed to the pregnancy loss, the family physician should optimize management of the patient's diabetes, thyroid disease, or hypertension. Many of the apartheid measures, including the extensive welfare system available to White people, the higher quality of education available to White students, and the formal and informal job reservations for White workers, was specifically designed in preventing poverty among the White population. Instead, it promoted the programme's health benefits and started to integrate family planning into other primary health care services. This suggests that the reproductive rights of majority of South African women are still under siege.
As a result, female-headed households are a common feature in disadvantaged rural and urban fringe areas. Again this suggests that there is a fair amount of unwanted childbearing amongst South African women.
Preventive measures, including vaccination and folic acid supplementation, are recommended regardless of risk. It is thus not surprising that, even for unmarried women and teenage girls, pregnancy has a positive value not generally experienced in white communities (Preston-White and others, 1990). Management of associated chromosomal factors requires consultation with a genetic counselor or obstetrician. Typically the membranes balloon into the vagina; this is followed by rupture of membranes, contractions, and expulsion of a premature fetus. On the contrary, poverty among 'Africans', the most disadvantaged group stands at 60,7% compared to 38,2%, and 5,4% for Coloureds and Asians. The negative implications of this situation manifest themselves as unwanted pregnancies, abortions, abandoned and street children, child neglect and abuse. The family physician can play an important role in helping the patient and her family cope with the emotional aspects of pregnancy loss. After an early pregnancy loss, women experience the same emotional and psychological reactions as those who have experienced any type of death; however, the duration of the distress is typically shorter. It is interesting to note, however, that the very few poor Asians and Whites also seem to be at a considerable distance below the poverty line. Patients should be questioned about cervical trauma during previous vaginal deliveries and any history of cone biopsy. Patients initially go through recognizable emotions, including shock, searching, and yearning. Often, the patient will have intense preoccupation with seeing or hearing the infant, and there may be a period of disorganization, with features similar to those of depression, before she gradually adjusts and is able to move on.35Many patients must also cope with their emotional responses during a subsequent pregnancy. These antibodies cause placental thrombosis and have emerged as well-established risks for second and third trimester pregnancy loss.25 Work-up of thrombophilia is, therefore, recommended in women with a pregnancy loss after 20 weeks' gestation.
During the next pregnancy, these patients may have intense anxiety and ambivalence, with little emotional attachment.

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