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1 Sex in Australia: Contraceptive practices among a representative sample of women Abstract Objectives: To document the use of contraception by a representative sample of Australian women aged years. Method: Between mid-2001 and mid-2002, computer-assisted telephone interviews were completed by 9,134 women aged years from all States and Territories selected by modified random-digit dialling of households (response rate 77.6%). Respondents were asked about contraceptive methods used in their current regular relationship(s) and during recent sexual encounters, or in general, or their reasons for non-use. Responses were allocated to 14 categories. Results: 70.8% of respondents were using a method of contraception, over 95% of those apparently at risk of pregnancy. Most common reasons for non-use were not having intercourse (41.6%) and being past menopause (21.6%). Among those apparently at risk of unplanned pregnancy (i.e. who were heterosexually active and fertile but not pregnant or trying to become pregnant; 13.0% of non-users), the most common reasons for non-use were experience of side-effects or contraindications (23.0%), leaving it to chance (20.2%), forgetting/not caring (18.9%), breast feeding (16.5%) and believing it unnatural/unhealthy (13.7%). No women cited religious objections or lack of access to services. The most used methods were oral contraceptives (33.6% of users), tubal ligation/hysterectomy (22.5%), condom (21.4%) and vasectomy of partner (19.3%). Tubal ligation rates were higher and condom use lower in regional and remote areas. Conclusion: Given the high levels of use and knowledge and lack of evidence of unmet service need, most unplanned pregnancies in Australian adults are likely to be attributable to method failure or inconsistent use. (Aust N Z J Public Health 2003; 27: 210-6) Juliet Richters National Centre in HIV Social Research, University of New South Wales Andrew E. Grulich National Centre in HIV Epidemiology and Clinical Research, University of New South Wales Richard O. de Visser, Anthony M.A. Smith Australian Research Centre in Sex, Health and Society, La Trobe University, Victoria Chris E. Rissel Health Promotion Unit, Central Sydney Area Health Service, and Australian Centre for Health Promotion, University of Sydney, New South Wales Access to a range of suitable contraceptive methods for the prevention of unplanned pregnancy is an essential component of sexual health care and is of considerable public health importance. However, the national sex surveys conducted in the 1990s were largely driven by a concern about HIV/AIDS and thus little attention was given to behaviour not directly related to HIV transmission, such as contraceptive behaviour. Some of the studies asked only about contraceptive use at first sex and thus provided no information about current contraceptive practices. In the 1992 United States National Health and Social Life Survey (NHSLS), 1 53% of men and 47% of women reported that they always used some form of contraception during intercourse with their primary partner; 69% of men and women used contraception at least some of the time. That study also revealed that 38% of women were infertile (29% had been sterilised by choice), as were 13% of men (12% had been sterilised by choice). Among both women and men, the prevalence of voluntary sterilisation was very low among young people and increased with age: more than 40% of women aged over 40 had been sterilised by choice. In the 1990 British National Survey of Sexual Attitudes and Lifestyles (NATSAL-I), 2 among respondents who reported at least one heterosexual partner in the last year, 79% of women and 82% of men reported use of a method of contraception. Some of those reporting no method may have been pregnant, seeking pregnancy, or sterile for noncontraceptive reasons. The authors estimate that under 10% of sexually active people were unprotected against unplanned pregnancy. The forms of contraception most commonly used in the past year were oral contraceptives (the pill) (reported by 30% of men, 29% of women), condoms (37% of men and 26% of women) and male or female sterilisation (21% of men, 23% of women). (Respondents could list up to three methods used, so percentages total more than 100.) Younger respondents were significantly more likely than older people to report use of condoms or the pill, and less likely to report sterilisation. Sterilisation was more popular among married respondents. Social Correspondence to: Dr Juliet Richters, National Centre in HIV Social Research, University of New South Wales, Sydney, NSW Fax: (02) ; j.richters@unsw.edu.au 210 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 2
2 Contraceptive practices class was more strongly related to use or non-use of contraception in general than to choice of a particular method. Respondents from higher social classes were more likely to use contraception. The 1991 French national sex survey also found that younger people were more likely than older people to report condoms as their method of contraception. 3 It has been noted that this increase was accompanied by a decrease between 1994 and 1998 in the proportion of women aged with multiple partners using prescribed contraception, suggesting that single-risk prevention campaigns on AIDS may have led some women to pay less attention to the risk of unwanted pregnancy. 4 The Australian Family Project in 1986 included questions on contraceptive use. Santow reported that in 1986, 2-5% of women (depending on age group) were using traditional methods (periodic abstinence or withdrawal), with the higher use in the older age groups, and 10-55% used modern methods (spermicides, condoms, diaphragm, intrauterine device (IUD), pill), with the higher use in the younger age groups. 5 Of those in their 20s and 30s, the huge majority of those using modern reversible methods were on the pill. Sterilising operations (including hysterectomy as well as tubal ligation and vasectomy) protected 32% of those aged 30-34, ranging up to 62% of the age group. In the and age groups, 8% of women were currently pregnant, as were 11% of those aged Only 1% of women aged were pregnant. Women using no method constituted 18-34% of the sample. The study did not investigate reasons for non-use or ascertain the percentage of women who were exposed to the risk of unplanned pregnancy. The Family Project study asked women about what methods they had been using in past periods of their lives and thus built up a picture of the changes in contraceptive use from the 1950s to the 1980s. Santow notes the rapid and wide adoption of the pill after its release in 1961, the popularity of sterilisation from the 1970s onwards, and presciently suggests that sexually transmissible infections and AIDS might lead to a revival in the use of condoms if the motivation for their use was not entirely contraceptive. 5 The rising availability of birth control from the 1970s had a considerable demographic impact, leading to an increase in the median age at marriage and at first nuptial birth, and to a dramatic increase in the proportion of first births to women in their 30s (7.2% in and 18.6% in 1984). 6,7 The 1995 National Health Survey found that two-thirds of Australian women aged were using contraception. Of those using contraception, almost 40% were on the pill, 19% were sterilised and 18% used condoms. 8 The Australian Bureau of Statistics estimated that 15% of women presumably at risk of pregnancy were not using contraception. 8 There are few data about contraceptive practices gathered from a representative national sample of Australian women, and no recent detailed data. One of the aims of the Australian Study of Health and Relationships (ASHR) was to provide reliable estimates of contraceptive practices derived from a representative sample of Australian adults. Method The methodology used in the ASHR is described elsewhere in this issue of the Journal. 9 Briefly, between May 2001 and June 2002 computer-assisted telephone interviews were completed by a representative sample of 9,134 women aged years from all States and Territories. Respondents were selected by modified random-digit dialling, with oversampling of residents of some geographical areas. The overall response rate was 77.6%. Women were asked about contraceptive use within their regular relationships and contraceptive use during recent sexual encounters. Respondents who did not provide this information or who were not sexually active in the year before being interviewed reported on their contraceptive practice in general. Thus respondents may have provided data about contraceptive practices at one or more of three sections of the interview. These can be grouped into behavioural and mechanical methods, mostly used on each occasion of intercourse (condom, withdrawal (coitus interruptus), diaphragm or cervical cap, spermicide, female condom and safe period methods), reversible prescribed methods (the pill, intrauterine device, medroxyprogesterone (Depo-Provera) injection and progestogen implants) and permanent methods (tubal ligation, vasectomy and hysterectomy). Although hysterectomy is not medically indicated for contraceptive purposes alone, it has the incidental effect of producing sterility, so that hysterectomised women are not at risk of pregnancy. All fertility awareness methods used to guide periodic abstinence such as calendar rhythm, Billings or symptothermal method and NFP or natural family planning were coded as safe period. Women who stated that they used another method such as condoms, but only during their unsafe period or when they thought they were fertile, were also coded under safe period (see Text Box 1). Correlates of contraceptive practices examined in this paper included respondents ages recoded into five groups (16-19, 20-29, 30-39, and years) and cohabitation status (living with regular partner, not living with regular partner, no regular partner). Respondents who spoke a language other than English at home were classified as having a non-english-speaking background. Respondents reports of their highest completed level of education were recoded to distinguish between those who did not complete secondary school, those who had completed secondary school and those who had completed post-secondary education. Respondents postcodes were used with the Accessibility/Remoteness Index of Australia 10 to determine whether respondents lived in a major city, a regional area or a remote area. Respondents reports of their annual household income were used to identify those with low incomes (under $20,000), middle incomes ($20,000-$52,000) and high incomes (over $52,000). Respondents reports of their occupations were coded into the nine major categories of the Australian Standard Classification of Occupations, 11 and then recoded to distinguish between managerial/ professional, white-collar and blue-collar occupations. Data were weighted to adjust for the probability of household selection (households with more phone lines were more likely to be contacted) and to adjust for the probability of selection within a household (individuals living in households with more eligible 2003 VOL. 27 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 211
3 Richters et al. people were less likely to be selected). Data were then weighted to match the Australian population on the basis of age, gender and area of residence. As the entire sample of 19,307 (10,173 men and 9,134 women) was included in this second weighting procedure, results are based on that total number of interviews. However, the act of weighting the data to the 2001 Census means that we report on an adjusted sample of 9,729 men and 9,578 women (total 19,307). Text Box 1: Ascertainment of women s contraceptive practices and reasons for not using contraception. Question: In this relationship, is any kind of contraception being used? / Did you use any contraception? Question: What form of contraception is being used? (Interviewer reads out methods and ignores occasional failure to use methods. Interviewer uses code for safe period if another method not used when believed not fertile.) Contraceptive pill IUD Depo-Provera injection Implant Partner had a vasectomy Have had a tubal ligation/hysterectomy Condom Safe period (natural family planning, rhythm method, Billings method, symptothermal, periodic abstinence) Withdrawal (coitus interruptus, pulling out) Douching (washing) Diaphragm/cervical cap (Interviewer to prompt for foam/jelly use) Spermicide foam or jelly Female condom Other non-prescribed Don t know Refused Question: Do you use that every time; or another type or method as well? Question: Can you tell me why you are not using contraception? (Interviewer pauses and allocates response to category if possible). Interviewer prompts with the following question if necessary, Is it because you don t have intercourse, you want a baby, you are infertile, or do you have some reason you prefer not to?. Not having intercourse Want a baby Pregnant now Feeding now Use safe period (periodic abstinence, rhythm method, Billings method) He withdraws (pulls out) Partner is infertile or subfertile I am infertile Have been sterilised (tubal ligation) Partner has a vasectomy I had hysterectomy I am past menopause Don t care/don t worry/forget/stupid/never got pregnant Don t know what to do/don t know about methods Religious objection Leave it to chance/fate/god, when to have babies Believe it unnatural or unhealthy I experienced side effects/contraindications Would like to but can t/partner or parent doesn t allow/no access/no confidential service Use method (Interviewer goes back to use of contraception question) Refused The fact that these data have been weighted does not mean that the data presented require any particular form of interpretation. We have weighted to account for the specifics of our sample design and the fact that particular types of people were either overor under-represented. Thus, in reading the data presented do so on the understanding that they describe the Australian population aged years subject to the biases we have already noted. 9 Weighted data were analysed using the survey estimation commands in Stata Version Correlates of outcome variables were identified via univariate logistic regression analysis for dichotomous outcome variables and univariate linear regression analysis for continuous outcome variables. Percentages are presented in this report without standard errors or 95% confidence intervals. That decision was made with a view to both readability and brevity, and is in keeping with the style of reporting the results of studies of a similar scope and intent. 1,2,8 Further information about the precision of estimates is found elsewhere in this issue of the Journal. 13 Results Respondents were asked directly if they used any contraception. Women who reported that they did not use contraception were asked their reason for non-use. Some women then disclosed use of a permanent method such as tubal ligation or vasectomy or a behavioural method such as withdrawal or periodic abstinence. Presumably such women take the term contraception to refer only to temporary or medical methods such as the pill. A new variable was created to include such women, indicating whether respondents used any form of contraception; 70.8% of respondents used some form of contraception. Table 1 displays the proportions of women endorsing various reasons for not using contraception. Among women who were not using any contraception, the most common single reason for not doing so was that they were not having intercourse. This group includes women who have never had vaginal intercourse, women who are not currently having vaginal intercourse and women who do not have sex with men. More than a fifth of the women not using any contraception indicated that they were past menopause. Sixteen per cent said that they were either currently pregnant or trying to become pregnant. Infertility (on the part of either the respondent or her partner) was given by 7.1% of the 2,591 women as a reason for not using contraception. The proportion of women Table 1: Reasons for not using contraception. Reason given Women % (n=2,591) Not having intercourse 41.6 Past menopause 21.6 Pregnant now 8.5 Want a baby 7.7 Respondent is infertile 5.0 Partner is infertile 1.1 Both partners infertile 1.0 Other 13.0 Refused AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 2
4 Contraceptive practices who were currently pregnant was 0.6% among women aged 16-19, 5.0% among women aged 20-29, 4.1% among women aged 30-39, 0.4% among women aged and 0.0% among women aged In order to arrive at an estimated population at risk of unplanned pregnancy, we excluded women who had no male partners in the past year, or who were not having vaginal intercourse, women who said that they were past menopause, pregnant or trying to get pregnant, those who were infertile, and women who said that their partner was infertile. The remaining 13% of women apparently at risk of unplanned pregnancy are shown as the Other category in Table 1. Their reasons given for not using contraception are given in Table 2. Table 3 reports correlates of contraceptive use. Of 6,621 women exposed to the risk of unplanned pregnancy, 94.8% used some form of contraception. Use of contraception was not significantly related to age (p=0.446), non-english-speaking background (p=0.337), education (p=0.447), region of residence (p=0.733), income (p=0.151), occupational category (p=0.870) or partner status (p=0.374). Table 4 displays the proportion of women who reported use of each form of contraception. More than a third of Australian women using contraception reported taking the pill. Over 40% of women reported that either they or their partners had undergone sterilising operations. Condom use was reported by 21.4% of women. It is interesting to note that when asked specifically about condom use without reference to contraception, 27.6% of women reported that they had used a condom in the year before being interviewed. This discrepancy may be due to women making a distinction between condom use for contraception and condom use for disease prevention. It may also be related to the possibility that women may have used condoms at some time in the year prior to being interviewed, but that they do not currently use condoms as a form of contraception. About 8% of women reported using withdrawal and/or safe period methods as a form of birth control. Table 5 provides information about the association between use of the most common forms of contraception and a range of other Table 2: Main reason for not using contraception given by women apparently at risk of unplanned pregnancy. a Reasons for not using contraception Women % (n=336) Have experienced side-effects/contraindications 23.0 Leave it to chance/fate/god when to have babies 20.2 Don t care/don t worry/forget/have never got pregnant 18.9 Currently breast feeding 16.5 Believe it is unnatural or unhealthy 13.7 Don t know enough about what to do 1.1 Religious objection 0.0 Would like to but can t/partner or parent doesn t allow it/no access/ 0.0 no confidential service Reason not specified/missing 6.6 Note: (a) Women were defined as at risk of unplanned pregnancy if they had at least one male sexual partner in the last year, had had vaginal intercourse, were not past menopause, pregnant, trying to get pregnant or infertile, and their partner was not infertile. Table 3: Socio-demographic correlates of contraceptive use among women exposed to the risk of pregnancy. Women (%) n=6,621 Total 94.8 Age OR (95% CI) ( ) ( ) ( ) ( ) Language spoken at home English 94.9 Other ( ) Education Lower secondary 93.7 Secondary ( ) Post-secondary ( ) Region of residence Major city 94.4 Regional ( ) Remote ( ) Household income Low (<$20,000) 94.1 Middle ($20,000 $52,000) ( ) High (>$52,000) ( ) Occupational category Blue collar 95.7 White collar ( ) Manager/professional ( ) Partner status No regular partner 91.9 Regular partner (non-live-in) ( ) Lives with regular partner ( ) Table 4: Contraceptive methods used by women who used a form of contraception. Method Women % a (n=6,278) Oral contraceptive 33.6 Tubal ligation or hysterectomy 22.5 Condom 21.4 Male partner has had vasectomy 19.3 Withdrawal (coitus interruptus) 4.5 Safe period methods b 4.4 Progestogen injection c 1.5 Intrauterine device 1.2 Progestogen implant 1.1 Diaphragm or cervical cap 0.9 Spermicidal foam or jelly 0.2 Female condom <0.1 Douching 0.0 Notes: (a) Adds up to more than 100% because women could report use of more than one method. (b) Such as NFP ( natural family planning ), Billings, symptothermal and calendar rhythm used to guide periodic abstinence or in conjunction with another method. (c) Such as Depo-Provera VOL. 27 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 213
5 Richters et al. variables. Use of the pill was significantly related to the woman s age, with women over 30 significantly less likely to report current use (p<0.001). Use of the pill was significantly more likely among women with higher levels of education (p<0.001). It was also significantly more likely among women who were in a regular relationship but did not live with their partner (p<0.001). Use of oral contraceptives was not significantly related to non- English-speaking background (p=0.075), region of residence (p=0.969), income (p=0.581) or occupational category (p=0.849). Women aged over 30 years were significantly more likely than younger women to report tubal ligation or hysterectomy (p<0.001). Tubal ligation or hysterectomy was significantly more common among women with lower levels of education (p<0.001), women living in regional or remote areas (p<0.001), women with bluecollar occupations (p=0.044) and women living with a regular partner (p<0.001). Reporting tubal ligation or hysterectomy was not significantly related to non-english-speaking background (p=0.569) or income (p=0.120). Use of condoms as a contraceptive method was significantly related to age, with much lower use of condoms among older women (p<0.001). Condom use was significantly more common among women from non-english-speaking backgrounds (p=0.043), women with higher levels of education (p<0.001), women living in major cities (p<0.001) and women with lower incomes (p=0.001). Women who lived with a regular partner were significantly less likely to report using condoms (p<0.001). Condom use was not significantly related to occupational category (p=0.501). Reporting vasectomy was significantly more common among women aged over 30 (p<0.001) and those with higher incomes (p=0.010). Vasectomy was reported significantly more often by women who lived with a regular partner (p<0.001). Vasectomy was not significantly related to being from a non-english-speaking background (p=0.052), level of education (p=0.172), region of residence (p=0.475) or occupational classification (p=0.372). Reporting withdrawal as a form of contraception was significantly more likely among women from non-english-speaking backgrounds (p=0.034). Withdrawal was less common among women living in regional areas (p=0.012). Women who had a regular partner they did not live with were the most likely to report using withdrawal (p=0.04). Use of this method was not significantly related to age (p=0.067), level of education (p=0.436), income (p=0.069) or occupational category (p=0.972). Safe period methods were reported significantly more often by Table 5: Socio-demographic correlates of use of most commonly used forms of contraception among women exposed to the risk of pregnancy (n=6,621). Contraceptive Tubal ligation/ Condom Vasectomy Withdrawal Safe period pill % hysterectomy % % % % methods % a Age Language spoken at home English Other Education Less than secondary Secondary Post-secondary Region of residence Major city Regional Remote Household income Low (<$20,000) Middle ($20,000-$52,000) High (>$52,000) Occupational category Blue collar White collar Manager/professional Partner status No regular partner Regular partner (non-live-in) Lives with regular partner Note: (a) Such as NFP ( natural family planning ), Billings, symptothermal and calendar rhythm used to guide periodic abstinence or in conjunction with another method. 214 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 2
6 Contraceptive practices women from non-english-speaking backgrounds (p=0.026). Women living in remote areas were significantly less likely to practise safe period methods (p=0.002). Safe period methods were significantly more likely to be reported by women who lived with a regular partner (p<0.001). Use of safe period methods was not significantly related to age (p=0.121), level of education (p=0.625), income (p=0.330) or occupational category (p=0.716). Discussion More than 70% of Australian women used some form of contraception. Only 5% of those apparently at risk of unplanned pregnancy were not using contraception at least some of the time. We did not investigate consistency of use. Some women who reported no method in a relationship or at last intercourse may have employed emergency contraception after being exposed to risk. This is reported in the accompanying paper on reproductive experiences. 14 The relationship between use and non-use of planned contraception and use of emergency contraception warrants investigation. Wide use of effective reversible methods, especially the pill, has accompanied and contributed to the continuing trend towards delay in childbearing. In 1986, childbearing peaked in the late 20s and dropped sharply in the mid-30s and overall rates of current pregnancy were considerably higher than we found. The complexity of the possible answers to the question Can you tell me why you are not using contraception? stretched the limits of what can be achieved in the context of a telephone interview with fixed response categories. The interviewers did not read out all 20 response options; rather they asked the question, then paused and allocated the woman s free response to a category if possible. No women claimed religious objections to using contraception. It is possible that some women whose religious background may have influenced their views of contraception expressed this in terms of the perception that contraception had been or might be unhealthy for them, and therefore offered the response that they had experienced side-effects or contraindications (although strictly speaking this is a reason only for preferring a certain method, not for complete non-use), or that they considered contraception unnatural or unhealthy, rather than raise the issue of religion. One in five at-risk non-users said they left it to chance when to have babies. Our finding for the proportion of women at risk of pregnancy but not using contraception is lower than the 1995 National Health Survey s 15%; this may reflect better ascertainment of nonexposure to risk permitted by our question about reasons for nonuse. Surprisingly, contraceptive use does not appear to decline after age 40 even though few women defined themselves as infertile. Our category of women presumably exposed to the risk of pregnancy may still be an overestimate, as many women who reported they had had trouble getting pregnant 14 did not label themselves as infertile when asked about contraceptive non-use. Our results provide no evidence of lack of access to services resulting in unmet need for contraception. No women said they would like to use contraception but could not do so because of being prevented by a parent or partner. Women may have preferred to decline to answer rather than volunteer that a partner or parent prevented them acting freely; this may partly explain the missing-answer and refusal rate. No women indicated that they did not use contraception because they did not have access to suitable services. However, the higher use of sterilisation among women in regional and remote areas may reflect a relative lack of access to services outside cities for women seeking alternatives to the pill, whether for confidential purchase of condoms or for abortion in the event of failure of a behavioural or mechanical method. Although we found the expected shifts with age from reversible methods such as the pill and condoms to permanent methods such as tubal ligation and vasectomy, use of permanent methods is lower than in This probably reflects both the trend to later childbearing in the 1980s and 1990s and the fact that most of our respondents commenced their sexual lives after abortion effectively became legally available in most States, 15 thus reducing the cost attached to continuing with a reversible method and its risk of failure. Very few women gave ignorance as a reason for not using contraception. In light of the high levels of contraceptive use, knowledge and access to services, the bulk of Australia s unplanned pregnancies are likely to be attributable to method failure or inconsistent use. Contraceptive use was lower, but not statistically significantly lower, among at-risk women under 20. Further analysis is needed of the reasons for this, but the small numbers of women surveyed in this age group limit the capacity of our data to address the question. Australia s teenage pregnancy rate is lower than that of the United States, the United Kingdom or New Zealand, but considerably higher than many European countries, so there is room for improvement. Acknowledgements This study was made possible through funding from the Commonwealth Department of Health and Ageing, the Victorian Health Promotion Foundation, the health departments of New South Wales, Queensland and Western Australia, and the Central Sydney Area Health Service. Our work was supported by the Australian Research Centre in Sex, Health and Society (La Trobe University), Central Sydney Area Health Service and the Australian Centre for Health Promotion (University of Sydney), the National Centre in HIV Social Research (University of New South Wales) and the National Centre in HIV Epidemiology and Clinical Research (University of New South Wales). Jeanette Ward, Sandy Gifford, Aileen Plant, Louisa Jorm and Elizabeth Proude were of particular assistance in the early stages of the study. The advice of the study s Advisory Committee of John Kaldor, Sue Kippax, Judy Simpson and Louisa Jorm is gratefully acknowledged as is the input of the representatives of Commonwealth Department of Health and Ageing who were members of the Advisory Committee over the life of the study: Paul Lehmann, Roger Nixon and Debra Gradie. We also wish to thank the many other colleagues 2003 VOL. 27 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 215
7 Richters et al. who offered advice on the content of questionnaire, particularly June Crawford, Basil Donovan, John Gagnon and norrie maywelby. We are indebted to the staff of the Hunter Valley Research Foundation who managed the data collection and undertook the interviewing for this study. The manuscripts were improved in response to comments made by anonymous reviewers and we thank the Editors and staff of the Journal for their careful stewardship of this issue. Finally, we thank the 20,776 Australians who took part in the three phases of the project and who shared so freely the sometimes intimate aspects of their personal lives. References 1. Laumann E, Gagnon J, Michael R, Michaels S. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press; Johnson A, Wadsworth J, Wellings K, Field J. Sexual Attitudes and Lifestyles. Oxford: Blackwell; Dubois-Arber F, Spencer B. Condom use. In: Hubert M, Bajos N, Sandfort T, editors. Sexual Behaviour and HIV/AIDS in Europe. London: UCL Press; p Bajos N, Warszawski J, Gremy I, Ducot B. AIDS and contraception. Unanticipated effects of AIDS prevention campaigns. Eur J Public Health 2001;11: Santow G. Trends in contraception and sterilization in Australia. Aust N Z J Obstet Gynaecol 1991;31: Siedlecky S. Current usage of and attitudes towards contraception in Australia. Healthright (Family Planning Association of NSW) 1986;6(1): Siedlecky S. A decade for women a decade of family planning. In: Kerby- Eaton E, Davies J, editors. Women s health in a changing society. Proceedings of the 2nd National Conference on Women s Health; 1985 September 4-7; Adelaide, Australia. Adelaide: Organising Committee, Second National Women s Health Conference; vol 3. p Australian Bureau of Statistics. National Health Survey Summary of Results, Australia. Canberra: ABS; ABS Catalogue No.: Smith AMA, Rissel CE, Richters J, Grulich AE, de Visser RO. Sex in Australia: the rationale and methods of the Australian Study of Health and Relationships. Aust N Z J Public Health 2003;27: Measuring Remoteness: Accessibility/ Remoteness Index of Australia (ARIA). Canberra: Commonwealth Department of Health and Aged Care; Australian Bureau of Statistics. Australian Standard Classification of Occupations, 2nd ed. Canberra: ABS; ABS Catalogue No.: STATA: statistical software [computer program]. Version 7.0. Texas: Stata Corporation; Smith AMA, Rissel CE, Richters J, Grulich AE, de Visser RO. Sex in Australia: a guide for readers. Aust N Z J Public Health 2003;27: Smith AMA, Rissel CE, Richters J, Grulich AE, de Visser RO. Sex in Australia: reproductive experiences and reproductive health among a representative sample of Australian women. Aust N Z J Public Health 2003;27: Ryan L, Ripper M. Women, abortion and the state. In: Howe R, editor. Women and the State: Australian Perspectives. Melbourne: La Trobe University Press; p AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 2
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