Developing the “120 by 20” Goal for the Global FP2020 Initiative

Modern contraceptive utilization and associated factors among postpartum women in Kena Woreda, Konso Zone, South Ethiopian Regional State, Ethiopia, 2023: mixed type community based cross-sectional study design

BACKGROUND

Even though family planning 2020 has made remarkable progress about solving the issue of unmet need for family planning, 70% of women in a developing countries who do not want to conceive are not using it. There are limited research that provided detail information regarding barriers of modern contraceptive utilization during postpartum period in the study area. In addition, previous study also recommended that to conduct using mixed quantitative and qualitative design for further investigations to answer these "why" questions and narrow these gaps.

OBJECTIVE

This study aimed to assess postpartum modern contraceptive utilization and associated factors among postpartum women in Kena woreda, Konso zone, South Ethiopian Regional State, Ethiopia, 2023.

METHODS

A mixed type community based cross-sectional study design was conducted among 605 women in Kena woreda, from September 1-30/2023 out of 628 sampled mothers. Multistage sampling technique was used to select study participant and data was collected using semi-structured pretested questionnaire and entered in to Epi data version 3.1 and then exported to STATA version 14 for analysis for quantitative. The association between variables was analyzed using bivariate and multivariable binary logistic regression and level of significant determined with adjusted odd ratio at 95% CI and P-value less than < 0.05. After translation and transcription, manual thematic analysis was applied to the qualitative data.

RESULTS

The prevalence of modern contraceptive use among women during postpartum period in Kena woreda was found to be 39.01% [95% CI: 35.18-42.96%]. Menses resumed (AOR = 1.63; 95% CI: 1.02, 2.59), linked to the family planning unit during their child`s immunization (AOR = 2.17; 95% CI: 1.45, 3.25), family planning counselling during antenatal care visit (AOR = 1.63; 95% CI: 1.10, 2.42) and good knowledge towards modern contraceptive (AOR = 1.53; 95% CI: 1.03, 2.26) were factors associated with postpartum contraceptive utilization. Partner oppose, myths and misconception, need for excess family size, religious prohibition, fear of side effect,menses not resumed, lack of counselling and privacy room, and lack of transportation to health facility were barriers to modern postpartum contraceptive utilization.   CONCLUSIONS AND RECOMMENDATIONS: The utilization of postpartum contraceptives was found to be lower than the target set by the 2020/21 national reproductive health strategy plan, which aimed to increase contraceptive method usage to 50%. Menses resumed, family planning counselling during antenatal care visit, linked to the family planning unit during child immunization and good knowledge were factors associated to modern postpartum contraceptive utilization. Strengthening service integration and family planning counseling during antenatal care visits and encourage mothers to start using modern family planning methods before menses resume are important. Overcoming barriers including partner opposition, myths, religious beliefs, fear of side effects, lack of counseling at health facilities, and transportation challenges is essential.

Modern contraceptive use and associated factors among reproductive-age women in Ethiopia: multilevel analysis evidence from 2019 Ethiopia mini demographic and health survey

BACKGROUND

Despite the high fertility and population growth rates, the use of modern contraceptives remains low in low- and middle-income countries. Different pocket-sized studies on the use of modern contraceptive methods conducted in various parts of Ethiopia have been extremely varied and ambiguous. Therefore, this study aimed to assess modern contraceptive use and its associated factors in women of reproductive age in Ethiopia.

METHODS

Cross-sectional data from the Ethiopia Interim Demographic Health Survey (EMDHS) 2019 in a stratified, two-stage, and cluster sampling study. Multilevel binary logistic regression analysis was used to fit the associated factors. The interclass correlation (ICC), median odds ratio (MOR), proportional change variance (PVC), and deviance were used for model comparison and fitness. The adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to identify the significant factors of modern contraceptive use.

RESULT

The multilevel analysis demonstrated that Orthodox religion [AOR = 1.7; 95%CI: 1.4-2.10] protestant religion [AOR = 1.2; 95%CI: 0.93-1.62], married [AOR = 4.2; 95%CI: 1.93-9.07], primary education [AOR = 1.5; 95%CI: 1.26-1.76], secondary education [AOR = 1.36; 95%CI: 1.04-1.77 [AOR = 1.89; 95%CI: 1.37-2.61], middle [AOR = 1.4; 95%CI: 1.14-1.73], rich [AOR = 1.3; 95%CI: 1.06-2.68] were positively associated with modern contraceptive utilization, while the age group of 40-49 [AOR = 0.45, 95% CI: 0.34-0.58], and high community poverty [AOR = 0.62; 95%CI: 0.46-0.83] were negatively associated with modern contraceptive utilization.

CONCLUSION

The prevalence of modern contraception in Ethiopia remains low. Maternal age, religion, maternal education, marital status, wealth index, region, and community poverty were significant predictors of modern contraceptive utilization in Ethiopia. Governments and non-governmental organizations should expand their public health programs to poorer communities to increase the use of modern contraception in the country.

Changes in discourse on unmet need for family planning among married women in India: evidence from NFHS-5 (2019-2021)

Unmet needs for contraception in India have declined over time but the rate has not been uniform among women across geographies and socio-economic strata. Identifying the characteristics of women in communities where unmet need is still high is important to devise appropriate strategies to ensure access and uptake of modern contraceptive methods. The current study examined whether there was a national decline in unmet need over time and if regional disparities exist in unmet need. Demographic variations in unmet need based on factors such as maternal age, education, religion, caste, wealth index quintile, family size, and access to antenatal care (ANC) were also documented. Our approach was to document the prevalence of total unmet need for family planning and unmet need for spacing among married Indian women and quantify variability based on socio-economic and demographic drivers within a hierarchal framework, thus providing both macro and micro perspectives. We used data from the fourth and fifth rounds of the National Family Health Survey (NFHS) collected from all the States and Union Territories (UTs) in India. Quantile regression analysis and multilevel regression techniques were used to understand the predictors for the total unmet need for family planning and the unmet need for spacing. Results show a considerable decline in the prevalence of unmet need for family planning in India from NFHS-4 to 5 (from 12.9 to 9.3%) in the last six6 years. The north-eastern states show a significant reduction in unmet need for family planning in Manipur (17.8%), Nagaland (13.5%), and followed by Sikkim (9.1%). The predictors such as years of schooling, place of residence, caste, religion, wealth quintile, number of antenatal care (ANC) visits, and children ever born have a significant association with unmet needs for family planning and spacing among married women in India. There is a significant association between years of schooling with the total unmet needs for family planning at (q25) quantiles and the unmet need for spacing at (q25, q50) quantiles. Results reveal that the demand for unmet need for spacing and limiting was the highest among the women in the age categories 15-19 (17.8%) and 20-24 (17.3%). The demand for limiting was the highest (6.8%) among Muslim women. Across wealth quantile categories, the overall unmet demand (11.4%) for spacing and limiting was the highest among the women in the lowest socioeconomic groups. We conclude that greater access to frontline health workers among young wives, and significant investment in education in general, will continue to reduce the unmet needs for family planning in India.

Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review

Background

Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population.

Methods

We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review.

Results

Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services.

Conclusion

The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.

Exploring Upward and Downward Provider Biases in Family Planning: The Case of Parity

INTRODUCTION

Provider bias has become an important topic of family planning research over the past several decades. Much existing research on provider bias has focused on the ways providers restrict access to contraception. Here, we propose a distinction between the classical "downward" provider bias that discourages contraceptive use and a new conception of "upward" provider bias that occurs when providers pressure or encourage clients to adopt contraception.

METHODS

Using cross-sectional data from reproductive-aged women in Burkina Faso, we describe lifetime prevalence of experiencing provider encouragement to use contraception due to provider perceptions of high parity (a type of upward provider bias) and provider discouragement from using contraception due to provider perceptions of low parity (a type of downward provider bias). We also examine associations between sociodemographic characteristics and experiences of provider encouragement to use contraception due to perceptions of high parity.

RESULTS

Sixteen percent of participants reported that a provider had encouraged them to use contraception due to provider perceptions of high parity, and 1% of participants reported that a provider had discouraged them from using contraception because of provider perceptions of low parity. Being married, being from the rural site, having higher parity, and having attended the 45th-day postpartum check-up were associated with increased odds of being encouraged to use contraception due to provider perceptions of high parity.

CONCLUSION

We find that experiences of upward provider bias linked to provider perceptions of high parity were considerably more common in this setting than downward provider bias linked to perceptions of low parity. Research into the mechanisms through which upward provider bias operates and how it may be mitigated is imperative to promote contraceptive autonomy.

Women's marital status and use of family planning services across male- and female-headed households in low- and middle-income countries

Background

As more households are being led by women, who are often seen as disadvantaged, more attention is being given to the potential association of female household headship with health. We aimed to assess how demand for family planning satisfied by modern methods (mDFPS) is associated with residence in female or male headed households and how this intersects with marital status and sexual activity.

Methods

We used data from national health surveys carried out in 59 low- and middle-income countries between 2010 and 2020. We included all women aged 15 to 49 years in our analysis, regardless of their relationship with the household head. We explored mDFPS according to household headship and its intersectionality with the women's marital status. We identified households as male-headed households (MHH) or female-headed households (FHH), and classified marital status as not married/in a union, married with the partner living in the household, and married with the partner living elsewhere. Other descriptive variables were time since the last sexual intercourse and reason for not using contraceptives.

Results

We found statistically significant differences in mDFPS by household headship among reproductive age women in 32 of the 59 countries, with higher mDFPS among women living in MHH in 27 of these 32 countries. We also found large gaps in Bangladesh (FHH = 38%, MHH = 75%), Afghanistan (FHH = 14%, MHH = 40%) and Egypt (FHH = 56%, MHH = 80%). mDFPS was lower among married women with the partner living elsewhere, a common situation in FHH. The proportions of women with no sexual activity in the last six months and who did not use contraception due to infrequent sex were higher in FHH.

Conclusions

Our findings indicate that a relationship exists between household headship, marital status, sexual activity, and mDFPS. The lower mDFPS we observed among women from FHH seems to be primarily associated with their lower risk of pregnancy; although women from FHH are married, their partners frequently do not live with them, and they are less sexually active than women in MHH.

Meeting Preferences for Specific Contraceptive Methods: An Overdue Indicator

Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.

Trends and Drivers of Unmet Need for Family Planning in Currently Married Tanzanian Women between 1999 and 2016

The current study investigated the trends and factors associated with the unmet need for family planning (FP) for limiting and spacing births among married Tanzanian women between 1999 and 2016. The study used Tanzania Demographic and Health Survey (TDHS) data for the years 1999 (N = 2653), 2004-2005 (N = 2950), 2010 (N = 6412), and 2015-2016 (N = 8210). Trends in the unmet need for FP were estimated over the study period. Multivariable multinomial logistic regression models were used to investigate the association between community-level, predisposing, enabling, and need factors with the unmet need for FP in Tanzania. The results showed no significant change in percentage of married women with an unmet need for birth spacing between 1999 and 2016. The proportion of married women with an unmet need for limiting births decreased from 9.5% (95% confidence interval (CI): 7.9%, 10.6%) in 1999 to 6.6% (95% CI: 5.9%, 7.3%) in 2016. Residing in a rural area, parity between 1-4 and 5+, visiting a health facility for any health services within twelve months, and planning to have more children (after two years and/or undecided) were factors positively associated with the unmet need for FP-spacing. Women with parity of 5+ were more likely to experience an unmet need for FP-limiting. Women's age between 25-34 and 35-49 years, women's employment status, watching television, women's autonomy of not being involved in household decisions, and planning to have more children were factors associated with lower odds of having an unmet need for FP-spacing. Women's age between 25-34 years, watching television, autonomy, and planning to have more children were factors with lower odds of having an unmet need for FP-limiting. Improving FP uptake among married Tanzanian women can reduce the unmet need for FP. Therefore, reducing unmet needs for FP is attainable if government policies and interventions can target women residing in rural areas and other modifiable risk factors, such as parity, health facility visits, planning to having more children, employment, watching television, and women's autonomy.

Unmet need for family planning among married women in sub-Saharan Africa: a meta-analysis of DHS data (1995 - 2020)

BACKGROUND

Closing the gap of unmet needs for family planning (FP) in sub-Saharan Africa remains critical in improving maternal and child health outcomes. Determining the prevalence of unmet needs for family planning among married women in the reproductive age is vital for designing effective sexual reproductive health interventions and programmes. Here, we use nationally representative data drawn from sub-Saharan countries to estimate and examine heterogeneity of unmet needs for family planning among currently married women of reproductive age.

METHODS

This study used secondary data from Demographic and Health Surveys (DHS) conducted between January 1, 1995 to December 31, 2020 from 37 countries in sub-Saharan African. An Inverse Heterogeneity model (IVhet) in MetaXL application was used to estimate country and sub-regional level pooled estimates and confidence intervals of unmet needs for FP in SSA.

RESULTS

The overall prevalence of unmet need for family planning among married women of reproductive age in the sub-region for the period under study was 22.9% (95% CI: 20.9-25.0). The prevalence varied across countries from 10% (95% CI: 10-11%) in Zimbabwe to 38% (95% CI: 35-40) and 38 (95% CI: 37-39) (I2 = 99.8% and p-value < 0.0001) in Sao Tome and Principe and Angola, respectively. Unmet needs due to limiting ranged from 6%; (95% CI: 3-9) in Central Africa to 9%; (95% CI: 8-11) in East Africa. On the other hand, the prevalence of unmet needs due to spacing was highest in Central Africa (Prev: 18; 95% CI: 16-21) and lowest in Southern Africa (Prev: 12%; 95% CI: 8-16). Our study indicates that there was no publication bias because the Luis Furuya-Kanamori index (0.79) was within the symmetry range of -1 and + 1.

CONCLUSION

The prevalence of unmet need for FP remains high in sub-Saharan Africa suggesting the need for health policymakers to consider re-evaluating the current SRH policies and programmes with the view of redesigning the present successful strategies to address the problem.

Reason and Associated Factors for Nonuse of Contraceptives Among Ethiopian Rural Married Women: A Multilevel Mixed Effect Analysis

Introduction

Contraception has a clear impact on the health of women and families in developing countries. This study aims to identify multilevel determinants of nonuse of modern contraceptives among Ethiopian rural married women in their productive age group.

Method

The study relied on data from the 2016 Ethiopian Demographic and Health Surveys. A multilevel logistic regression model was used for analysis.

Result

In rural areas, nonuse of modern contraceptives is surprising high (81.7%), primarily due to fear of side effects (12.89%) and breastfeeding (8.2%). Among women aged 35 to 49 years (adjusted odds ratio [AOR] = 0.66; 95% confidence interval [CI]: 0.540.81), husbands with secondary and above education levels (AOR = 0.83; 95% CI: 0.7-1), those in the high wealth index (AOR = 0.61; 95% CI: 0.51-0.72), and those who have had 1 to 2 children in the past 5 years (AOR  =  0.28; 95% CI: 0.24-0.33), there was a lower chance of not using contraception. Muslims are less likely to want to use modern contraceptives (AOR = 1.2; 95% CI: 0.96-1.4). Women living in Afar (AOR  =  20.9; 95% CI: 9.6-44.7), Oromia (AOR =  1.5; 95% CI: 1.01-2.3), Somali (AOR = 71.1; 95% CI: 24.1-209.2), Gambela (AOR = 2.3; 95% CI: 1.4-3.9), Harari (AOR  =  4.4; 95% CI: 2.24-8.72), and Dire Dawa (AOR = 3.2; 95% CI: 1.5-6.9), regional states, were less likely to want to use modern contraceptives as compared to those in Tigray.

Conclusion

Family planning interventions should target younger women, women living in rural areas, the poor, and Muslim women. In order to maximize the effectiveness of family planning promotion policies, it's important to address the reasons for nonuse of contraceptives identified in each region and contextual differences regarding women of reproductive age.

The effect of a postpartum intrauterine device programme on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial

Vertical global health programmes often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum intrauterine device (PPIUD) intervention on outcomes related to contraceptive method choice. The stepped-wedge cluster randomized contolled trial (RCT) took place in five Tanzanian hospitals. Hospitals were randomized to receive immediate (Group 1; n = 11 483 participants) or delayed (Group 2; n = 8148 participants) intervention. The intervention trained providers on PPIUD insertion and counselling. The evaluation surveyed eligible women (18+, resided in Tanzania, gave birth at a study hospital) on provider postpartum contraceptive counselling during pregnancy or immediately postpartum. In our completed study, participants were considered exposed (n = 9786) or unexposed (n = 10 145) to the intervention based on the location and timing of their birth (no blinding). Our secondary analysis examined differences by intervention exposure on the likelihood of being counselled on IUD only, multiple methods, multiple method durations, a broad method mix; and on the number of methods women were counselled across two samples: all eligible women, and only women who reported receiving any contraceptive counselling. Among all eligible women, counselling on the IUD alone was 7% points higher among the exposed (95% confidence interal (CI): 0.02, 0.12). Among women who received any counselling, those exposed to the intervention were counselled on 1.12 fewer contraceptive methods (95% CI: 0.10, 2.34). The likelihood of receiving counselling on any non-IUD method decreased among those exposed, while the likelihood of being counselled on an IUD alone was 14% points higher among the exposed (95% CI: 0.06, 0.22), suggesting this intervention increased IUD-specific counselling but reduced informed contraceptive choice. These findings underscore the importance of broad metrics that capture autonomy and rights (in addition to programmatic goals) at all stages of health programme planning and implementation.

Awareness and access to mass media sources of information about modern family planning methods among women with disabilities in Nigeria: An analysis of 2018 demographic and health survey

BACKGROUND

Family planning is the foundation of sexual and reproductive health, and necessary for achieving the Sustainable Development Goals. Yet, the needs of women with disabilities and their access to these services have been neglected for decades, especially in Low and Middle-income Countries. To improve utilization of these services among women with disabilities, they have to be aware and informed about the services. This study was conducted to examine awareness and mass media sources of information on family planning between women with and without disabilities.

METHODS

This study used data from the 2018 Nigeria Demographic and Health Surveys (NDHS). Our analytic sample included 26,585 women between 15 and 49 years of age who answered the disability module. We compared demographics and socioeconomic characteristics of women with and without disabilities using the chi-square test for categorical variables. In addition, we conducted logistic regressions to estimate the unadjusted and adjusted odds ratio (with 95% confidence intervals) for level of awareness and mass media sources of information on modern contraceptive methods, using women without a disability as the reference group.

RESULTS

Finding showed that women with disabilities have poor awareness about family planning compared to women without disabilities even after adjusting for all covariates (AOR = 0.42, 95% CI: 0.23-0.76, P < 0.05). We also found that women with disabilities are less likely to receive information about family planning from any of the available mass media channels even after adjusting for covariates (AOR = 0.46, 95% CI: 0.22-0.98, P < 0.05).

CONCLUSIONS

The study revealed that women with disabilities Nigeria have poor awareness about modern family planning methods compared to non-disabled women. They are also less likely to receive information about modern family planning methods compared to non-disabled women. To effectively reach women with disabilities, information barriers must be eliminated, coupled with increased opportunities to access family planning information. Donors, government, and other relevant stakeholders should consider funding inclusive campaigns and explore other mechanisms for disseminating family planning information to women with disabilities.

Intimate Partner Violence and Unmet Need for Family Planning in Selected South Asian Countries

This article analyzes the relationship between various forms of intimate partner violence (IPV) and unmet need for family planning (FP) in South Asia. The data were obtained from the latest wave of the Demographic and Health Survey in Afghanistan, India, Maldives, Nepal, and Pakistan. Binary logistic regression analyses show mixed results, with a significant association between at least one type of IPV and unmet need for FP in all countries under study, except Maldives. There were also contrasting findings on the IPV-unmet need nexus, with a positive sign in some but negative sign in others. Women who experienced physical violence were associated with a higher odds of having an unmet need in Pakistan, but the opposite was true in Afghanistan and Nepal. The odds of having an unmet need were higher among Indian women who experienced IPV (sexual and emotional). In Afghanistan, women who experienced IPV (physical and emotional) have lower odds of having an unmet need. However, the interaction analysis of IPV (physical and sexual) and partners' controlling behavior showed a positive association with unmet need. Policymakers need to develop policies and strategies to prevent IPV and reduce unmet need for FP, in line with the Sustainable Development Goals.

Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs

Despite its central importance to global family planning, the "unmet need for contraception" metric is frequently misinterpreted. Often conflated with a lack of access, misinterpretation of what unmet need means and how it is measured has important implications for family planning programs. We review previous examinations of unmet need, with a focus on the roles of access and demand for contraception, as well as the role of population control in shaping the indicator's priorities. We suggest that disaggregating unmet need into "demand-side unmet need" (stemming from lack of demand) and "supply-side unmet need" (stemming from lack of access) could allow current data to be leveraged into a more person-centered understanding of contraceptive need. We use Demographic and Health Survey data from seven sub-Saharan African countries to generate a proof-of-concept, dividing women into unmet need categories based on reason for contraceptive nonuse. We perform sensitivity analyses with varying conceptions of access and disaggregate by education and marital status. We find that demand-side unmet need far exceeds supply-side unmet need in all scenarios. Focusing on supply-side rather than overall unmet need is an imperfect but productive step toward person-centered measurement, while more sweeping changes to family planning measurement are still required.

Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Meeting the contraceptive needs of women of reproductive age is beneficial for the health of women and children, and the economic and social empowerment of women. Higher rates of contraceptive coverage have been linked to the availability of a more diverse range of contraceptive methods. We present estimates of the contraceptive prevalence rate (CPR), modern contraceptive prevalence rate (mCPR), demand satisfied, and the method of contraception used for both partnered and unpartnered women for 5-year age groups in 204 countries and territories between 1970 and 2019.

METHODS

We used 1162 population-based surveys capturing contraceptive use among women between 1970 and 2019, in which women of reproductive age (15-49 years) self-reported their, or their partner's, current use of contraception for family planning purposes. Spatiotemporal Gaussian process regression was used to generate estimates of the CPR, mCPR, demand satisfied, and method mix by age and marital status. We assessed how age-specific mCPR and demand satisfied changed with the Socio-demographic Index (SDI), a measure of social and economic development, using the meta-regression Bayesian, regularised, trimmed method from the Global Burden of Diseases, Injuries, and Risk Factors Study.

FINDINGS

In 2019, 162·9 million (95% uncertainty interval [UI] 155·6-170·2) women had unmet need for contraception, of whom 29·3% (27·9-30·6) resided in sub-Saharan Africa and 27·2% (24·4-30·3) resided in south Asia. Women aged 15-19 years (64·8% [62·9-66·7]) and 20-24 years (71·9% [68·9-74·2]) had the lowest rates of demand satisfied, with 43·2 million (95% UI 39·3-48·0) women aged 15-24 years with unmet need in 2019. The mCPR and demand satisfied among women aged 15-19 years were substantially lower than among women aged 20-49 years at SDI values below 60 (on a 0-100 scale), but began to equalise as SDI increased above 60. Between 1970 and 2019, the global mCPR increased by 20·1 percentage points (95% UI 18·7-21·6). During this time, traditional methods declined as a proportion of all contraceptive methods, whereas the use of implants, injections, female sterilisation, and condoms increased. Method mix differs substantially depending on age and geography, with the share of female sterilisation increasing with age and comprising more than 50% of methods in use in south Asia. In 28 countries, one method was used by more than 50% of users in 2019.

INTERPRETATION

The dominance of one contraceptive method in some locations raises the question of whether family planning policies should aim to expand method mix or invest in making existing methods more accessible. Lower rates of demand satisfied among women aged 15-24 years are also concerning because unintended pregnancies before age 25 years can forestall or eliminate education and employment opportunities that lead to social and economic empowerment. Policy makers should strive to tailor family planning programmes to the preferences of the groups with the most need, while maintaining the programmes used by existing users.

FUNDING

Bill & Melinda Gates Foundation.

Two decades of family planning in Ethiopia and the way forward to sustain hard-fought gains!

Family planning (FP) is a human right, and ensuring women’s access to FP is central to protecting the health and wellbeing of mothers and children. Over the past two decades, Ethiopia has made FP service more widely available, increasing the contraceptive prevalence rate from 8% in 2000 to 41% in 2019. This remarkable fivefold increase can be attributed to the country’s overall development, including investment in education (particularly for girls) and reduction in child marriage, as well as the adoption and implementation of several enabling FP policies and strategies. In Ethiopia, achieving universal access to sexual and reproductive health care services, information, and education, including FP, by 2030 means enhancing these effective government policies and programs. Achieving universal access requires increasing financial resources, including domestic financing through greater government commitment for commodity security and program implementation; strengthening public–private partnerships; and improving service delivery for populations that are hard to reach and/or in humanitarian crisis. The persistence of equity gaps due to regional and/or sociodemographic disparities and the low quality of FP service delivery challenge our progress in Ethiopia. The papers included in this supplement provide additional detail on the overall progress described in this commentary and highlight focal areas for improvement in responding to unmet needs. Current policies and services must adapt, maintain, and build upon these gains and focus on targeted actions in areas identified for improvement. We must sustain the hard-fought gains of the past decades and help shape the prosperous future we advocate for in our society by 2030 and beyond—Leaving No One Behind.

Linking family planning market census data with consumer experiences in three countries: the Consumer’s Market for Family Planning study protocol and data

Background: The Consumer’s Market for Family Planning (CM4FP) project was designed to address limitations of existing family planning (FP) data sources that prevent a full understanding of the total FP market. CM4FP data provide a picture of the complete supply environment and how consumers experience it.

Study objectives were to 1) test a ring-fenced census approach consisting of an outlet census in a defined geographical area and a household survey in a smaller inner ring, to comprehensively map the total FP market in a local geography; 2) explore FP supply market dynamism through longitudinal data collection from contraceptive outlets; and 3) test a methodology for directly linking household and outlet data to measure the relationship between contraceptive demand and supply.

Methods: Data were collected from study sites in Nigeria, Kenya, and Uganda from 2019 to 2020. Longitudinal outlet census data and repeated cross-sectional household survey data from women ages 18-49 were collected at three quarterly time points. Outlets were located in an outer ring geography to encompass locations likely visited by women sampled from a smaller inner ring. Data from women who received a contraceptive method in the past 12 months were linked to data for the outlet from which they received the method.

Results: Datasets include product audits for 22,380 individual FP products, collected from a total of 1,836 outlets across 12 study sites. The datasets also contain data from 11,536 female respondents, of whom 1,975 were successfully matched to the outlet where they most recently obtained their method.

Conclusions: CM4FP data are available at www.cm4fp.org. This unique dataset enables in-depth exploration of the family planning supply market in addition to interactions between the market and consumer perspectives and behaviors within each study site. The data can also be used to explore novel methodologies to inform future study designs.

Unmet need for contraception and associated factors among women with cardiovascular disease having follow-up at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia: a cross-sectional study

Background

Unmet need for contraception refers to the proportion of women who want to postpone or stop childbearing but are not using a contraceptive method. Addressing unmet need is especially important for women with medical conditions such as cardiovascular disease (CVD). Preventing unintended pregnancy is crucial to improve pregnancy outcomes and minimize complications of CVD during pregnancy. However, unmet need for contraceptives continues to undermine the potential benefits of contraceptive use. This research aimed to determine the rate of unmet need for contraceptives and associated factors among women with cardiovascular disease having follow-up at Saint Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study was conducted from February 1 to May 31/2020. A total of 284 reproductive age women with cardiovascular disease having follow-up at the cardiac clinic of SPHMMC were enrolled consecutively until the desired sample size was reached. Data was collected through an exit interview using a structured and pretested questionnaire. Descriptive, bivariate, and multivariable methods were used to analyze the level of unmet need and its associated factors.

Results

The overall unmet need for contraception was 36.0% (95% CI: 30.4–41.5). The majority of the respondents lack counseling on contraception use. The most common reasons for non-use of a contraceptive method were fear of drug side effects and drug interaction. Unmet need for contraception was found to be more likely among those who have not been counseled on contraceptive utilization (AOR 6.7, CI 1.8–24.7) and those who lack partner support on contraception use (AOR = 6.2, CI: 1.91–19.8). Unmet need was also found to be more likely among women who have never used contraception before (AOR = 3.2, CI 1.12–8.92).

Conclusion

Unmet need for contraception was high in this high-risk population group. The cardiac follow-up clinic should implement client-centered counseling by a multidisciplinary team to address the needs of women and prevent consequences of unintended pregnancy. Furthermore, there is a need to initiate interventions that encourage communication between couples and increase male partner involvement through a renewed focus on couples counseling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40834-022-00173-0.

Let's Talk About Sex: Improving Measurement of Contraceptive Use in Cross-Sectional Surveys by Accounting for Sexual Activity Recency

Findings suggest that the contraceptive use of unmarried women and those who were not recently sexually active are less likely to be captured in standard measures of current contraceptive use. Incorporating information from questions about contraceptive use at last sex may better capture coital-dependent method use and provide a more accurate assessment of who is protected against an unintended pregnancy at next sex.

Introduction:

Standard measures of contraceptive prevalence have known biases given that they do not reflect sexual activity and true exposure to the risk of an unintended pregnancy. In this study, we aim to understand the extent to which women protect themselves against unintended pregnancy, taking into account exposure to sex, by examining contraceptive use patterns by marital status and recent sexual activity.

Methods:

Data come from population-based surveys of reproductive age women in 9 low-resource settings. We estimated contraceptive prevalence using (1) the standard current contraceptive use measure, (2) a new measure of contraceptive use at last sex, and (3) a comprehensive measure that combines current use and use at last sex. Analyses are stratified by site and examine patterns by marital status only, and by both marital status and sexual activity separately. We then examined method mix by each contraceptive measure.

Results:

Study findings reveal distinct patterns in contraceptive use in relation to marital status and sexual recency across sites. Overall, married women tended to report higher levels of current contraceptive use compared to use at last sex, whereas unmarried women reported higher levels of contraceptive use at last sex. When examining these measures by sexual activity and marital status, results indicate lower levels of contraceptive use among women who had not had sex in the month prior to the survey, for both married and unmarried women. The comprehensive measure of contraceptive use yielded the highest estimates, by design. Method mix varied consistently by contraceptive measure, with current use tending to capture more permanent and long-acting methods and use at last sex more likely to capture short-acting and coital-dependent methods.

Discussion:

These findings have important implications for how the family planning field evaluates unintended pregnancy risk and unmet need for contraception within low-resource settings, given different estimates yield discrepant estimates for who is “at risk.”

Language and Measurement of Contraceptive Need and Making These Indicators More Meaningful for Measuring Fertility Intentions of Women and Girls

We examine current “need”-based family planning measures that are based on women’s fertility desires and contraceptive use, identify challenges with language and use of need-based measures, and recommend ways to improve language and measurement.

Mass media influences on family planning knowledge, attitudes and method choice among sexually active men in sub-Saharan Africa

Men are underrepresented in family planning (FP) research, and despite the widespread promotion of FP through mass media, there is no systematic evaluation on how mass media exposure influences their FP knowledge, attitudes and behavior. Using Demographic and Health Survey (DHS) data from 31 countries in Sub-Saharan Africa (SSA), collected between 2010 and 2019, this paper examines the associations between three types of traditional mass media (radio, television and print) with FP knowledge, attitudes and method choices among reproductive age men in SSA, relative to other socio-cultural factors. Estimates to quantify the relative contribution of each type of mass media, relative to other evidence-based socio-cultural influences on FP outcomes, were derived using the Shorrocks-Shapley decomposition. Radio exposure had the largest impact on FP knowledge, attitudes and method choice, accounting for 26.1% of the variance in FP knowledge, followed by Television (21.4%) and education attainment (20.7%). Mass media exposure had relatively minimal impact on FP method choice, and between the three types of mass media, television (8%) had the largest influence on FP method choice. Print media had comparatively lesser impact on FP knowledge (8%), attitudes (6.2%) and method choice (3.2%). Findings suggest that mass media exposure has positive influences on FP knowledge, attitudes and method choice but its influence on FP knowledge, attitudes and method choice is smaller relative to other socio-cultural factors such as education, household wealth and marital status. As such, efforts to increase FP uptake in Sub-Saharan Africa should take into consideration the impact of these socio-cultural economic factors.

Linking family planning market census data with consumer experiences in three countries: the Consumer’s Market for Family Planning study protocol and data

Background: The Consumer’s Market for Family Planning (CM4FP) project was designed to address limitations of existing family planning (FP) data sources that prevent a full understanding of the total FP market. CM4FP data provide a picture of the complete supply environment and how consumers experience it. Study objectives were to 1) test a ring-fenced census approach consisting of an outlet census in a defined geographical area and a household survey in a smaller inner ring, to comprehensively map the total FP market in a local geography; 2) explore FP supply market dynamism through longitudinal data collection from contraceptive outlets; and 3) test a methodology for directly linking household and outlet data to measure the relationship between contraceptive demand and supply. Methods: Data were collected from study sites in Nigeria, Kenya, and Uganda from 2019 to 2020. Longitudinal outlet census data and repeated cross-sectional household survey data from women ages 18-49 were collected at three quarterly time points. Outlets were located in an outer ring geography to encompass locations likely visited by women sampled from a smaller inner ring. Data from women who received a contraceptive method in the past 12 months were linked to data for the outlet from which they received the method. Results: Datasets include product audits for 22,380 individual FP products, collected from a total of 1,836 outlets across 12 study sites. The datasets also contain data from 11,536 female respondents, of whom 1,975 were successfully matched to the outlet where they most recently obtained their method. Conclusions: CM4FP data are available at www.cm4fp.org. This unique dataset enables in-depth exploration of the family planning supply market in addition to interactions between the market and consumer perspectives and behaviors within each study site. The data can also be used to explore novel methodologies to inform future study designs.

A long way to go: engagement of men and boys in country family planning commitments and implementation plans

Background: To reach global goals related to women and girls’ access to modern family planning (FP) and gender equality, evidence shows that it is critical to understand and account for the role of men and boys as users of reproductive health services, as partners for millions of women & girls around the world, and as advocates in their communities. Under the Family Planning 2020 (FP2020) partnership, countries were encouraged to develop costed implementation plans and action plans in an effort to provide 120 million additional women and girls with contraception. As FP2020 becomes FP2030, reviewing these previously-developed strategies helps understand the extent to which countries considered the engagement of men as an important aspect of their family planning portfolios.

Methods: We conducted textual analysis on commitments and implementation plans related to achieving FP2020 commitments in six countries in Africa and one in Asia to determine the extent to which male engagement was incorporated into country or subnational family planning goals, with particular focus on FP policy, program, and financial commitments. 

Results: Some of the documents analyzed included robust plans for including male engagement in their efforts to expand access to FP.  The strongest aspects of male engagement programming were those that sought to engage men as advocates for women’s access to and use of FP services, and improve their knowledge and attitudes related to contraception and reproduction. The weakest aspects were engaging men as users of services and, vitally, tackling underlying gender norms which hamper men’s and women’s health-seeking behaviors and attitudes.

Conclusions: Developing FP programs that target men and boys as people deserving of reproductive health services, as partners with women in building their families, and as social activists in their communities, will complement and strengthen existing FP programs as well as promote broader goals related to gender equality.

Demographic and Fertility Characteristics of Contraceptive Clusters in Burundi

Examining women's reproductive experiences over time reveals a more dynamic view of women's behaviors and needs than current status measures alone. This study uses sequence and cluster analyses, which are designed for identifying patterns and subgroups in longitudinal data. We apply these methods to contraceptive calendar data in Burundi to identify discrete clusters of women based on contraceptive and pregnancy behaviors over the past 5 years. We identify six unique clusters; three characterized by no use of contraception (85 percent of women) and three by use (16 percent). The Quiet Calendar cluster (42 percent) comprise women who neither experience pregnancy nor use contraception. Family Builder 1 (25 percent) and 2 (18 percent) both include women who experience two pregnancies, but differ in unmet need and lifetime experience with contraception. Modern Mother (8 percent), Consistently Covered Mother (6 percent), and Traditional Mother (2 percent) clusters differ by type of contraception used following pregnancy. Factors associated with cluster membership are need for family planning, lifetime experience with contraception, marital status, pregnancy intention, and age. This clustering approach provides a new, more holistic way to measure the diverse needs across unique subpopulations and can inform the development of multifaceted, adaptable strategies to meet women's dynamic fertility needs over the reproductive life course.

Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption

Approximately 214 million women of reproductive age lack adequate access to contraception for their family planning needs, yet patterns of contraceptive availability have seldom been examined. With growing demand for contraceptives in some areas, low contraceptive method availability and stockouts are thought to be major drivers of unmet need among women of reproductive age, though evidence for this is limited. In this research, we examined trends in stockouts, method availability and consumption of specific contraceptive methods in urban areas of four sub-Saharan African countries (Burkina Faso, Democratic Republic of Congo, Kenya and Nigeria) and India. We used representative survey data from the Performance Monitoring for Action Agile Project that were collected in quarterly intervals at service delivery points (SDP) stratified by sector (public vs private), with all countries having five to six quarters of surveys between 2017 and 2019. Among SDPs that offer family planning, we calculated the percentage offering at least one type of modern contraceptive method (MCM) for each country and quarter, and by sector. We examined trends in the percentage of SDPs with stockouts and which currently offer condoms, emergency contraception, oral pills, injectables, intrauterine devices and implants. We also examined trends of client visits for specific methods and the resulting estimated protection from pregnancy by quarter and country. Across all countries, the vast majority of SDPs had at least one type of MCM in-stock during the study period. We find that the frequency of stockouts varies by method and sector and is much more dynamic than previously thought. While the availability and distribution of long-acting reversible contraceptives (LARCs) were limited compared to other methods across countries, LARCs nonetheless consistently accounted for a larger portion of couple years of protection. We discuss findings that show the importance of engaging the private sector towards achieving global and national family planning goals.

A long way to go: engagement of men and boys in country family planning commitments and implementation plans

Background: Evidence shows that, to reach global goals related to women and girls' access to modern family planning (FP) and gender equality, it is critical to understand and account for the role of men and boys as users of reproductive health services, as partners for millions of women & girls around the world, and as advocates in their communities. Under the Family Planning 2020 (FP2020) partnership, countries were encouraged to develop costed implementation plans and action plans in an effort to provide 120 million additional women and girls with contraception. As FP2020 becomes FP2030, reviewing these previously-developed strategies helps understand the extent to which countries considered the engagement of men as an important aspect of their family planning portfolios. Methods: We conducted textual analysis on commitments and implementation plans related to achieving FP2020 commitments in seven countries in Africa and one in Asia to determine the extent to which male engagement was incorporated into country or subnational family planning goals, with particular focus on FP policy, program, and financial commitments.  Results: Some of the documents analyzed included robust plans for including male engagement in their efforts to expand access to FP.  The strongest aspects of male engagement programming were those that sought to engage men as advocates for women's access to and use of FP services, and improve men's knowledge and attitudes related to contraception and reproduction. The weakest aspects were engaging men as users of services and, vitally, tackling underlying gender norms which hamper men's and women's health-seeking behaviors and attitudes. Conclusions: Developing FP programs that target men and boys as people deserving of reproductive health services, as partners with women in building their families, and as social activists in their communities, will complement and strengthen existing FP programs as well as promote broader goals related to gender equality.

Family planning science and practice lessons from the 2018 International Conference on Family Planning

Background Since 2009, the International Conference on Family Planning (ICFP) has served as an opportunity for the global reproductive health community to share FP advances and practice lessons in the areas of research, programming, and advocacy. The purpose of this paper was to synthesize the key results and findings presented by members of the FP community at the 2018 ICFP Conference. Methods More than 700 abstracts from all 15 conference tracks were reviewed and 64 abstracts total were selected for this paper based on the novelty and urgency of the findings. The content analysis of conference abstracts were grouped into six final thematic areas. Results 1 ) Investing in family planning for a lifetime of returns. FP continues to face a shortage of funding. Domestically based and locally owned funding models provide alternative financing solutions. 2) Addressing inequities in family planning for key populations. Various populations still face challenges in accessing FP. Youth-inclusive and user-centered programming show promise in addressing such challenges. 3) Reproductive justice, Unsafe abortions tend to be more common among younger, poor, uneducated and rural women. Legislation is still needed to facilitate a culture of safe abortions. 4) Couple dynamics and decision-making. Couples who share equitable responsibility in decision-making processes are more likely to use contraceptives; couple disagreement influences women's decisions to covertly use FP. 5) Male involvement in  programming. Male champions can successfully promote uptake of FP. Gender-transformative programming promotes gender equity and impacts behavior change. 6) Breakthroughs in novel contraceptives and systems improvement in family planning. Recent advances include user-centered contraceptive technologies that allow for self-administration and information systems which optimize supply chain management. Conclusion The research, advocacy, and programmatic abstracts at ICFP 2018 highlighted research advances, showcased implementation science wins, and provided evidence of critical knowledge gaps in global FP access and use.

Incorporating Method Dissatisfaction into Unmet Need for Contraception: Implications for Measurement and Impact

While unmet need for contraception is commonly used to assess programmatic needs, it inadequately captures the complexity of fertility and contraceptive preferences, including women's satisfaction with their contraceptive method. In their 2019 commentary, Sarah Rominski and Rob Stephenson propose reclassifying dissatisfied current users as having an unmet need for contraception. As revising the current definition based on their proposal would require significant investment to update survey and monitoring systems, understanding the potential impact on current estimates of unmet need is critical. We estimated the impact of this approach in a Kenyan cohort of modern contraceptive users. We found the prevalence of method dissatisfaction ranges from 6.6% (95% confidence interval [CI] 5.6–7.8%) to 18.9% (95% CI 17.1–20.9%); if applied nationally, this results in a large (approximately 25–70%) increase in Kenya's current estimate of unmet need for any contraception. Our findings suggest a large impact on unmet need estimates for equivalent populations. Overall, we advocate for better measurements of method satisfaction and acceptability, with metrics developed that are robust to socioeconomic gradients and validated in low‐ and middle‐income settings to ensure women's contraceptive needs are captured equitably.

Postpartum modern contraception utilization and its determinants in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Contraceptive use is the best and most cost-effective strategy to reduce feto-maternal adverse effects of short birth intervals. More than two-thirds of women in developing countries who do not want to conceive are not using contraception methods. Although there were various primary studies in different parts of the country, there is no nationally representative evidence on postpartum modern contraception utilization and its determinants in Ethiopia.

OBJECTIVE

This review was aimed to determine the best available pieces of evidence to pool the magnitude of postpartum modern contraception utilization and find out its determinants.

METHODS

Published studies were extensively searched by using electronic databases and unpublished studies were identified from the digital library. All observational studies conducted on the magnitude of postpartum modern contraception utilization and its determinants in Ethiopia were included. Data were extracted on the Microsoft Excel spreadsheet and analyzed using STATA 14.1 version. A random-effects model was used to estimate the pooled magnitude of postpartum modern contraception utilization with a 95% confidence interval (CI). Inverse variance (I2) was used to identify the presence of heterogeneity and forest plot was used to estimate the pooled magnitude of postpartum contraception utilization. The presence of publication bias was assessed by funnel plots and Egger's statistical tests. Sub-group analysis was computed to minimize underlying heterogeneity.

FINDINGS

In this review, 19 primary studies were included. The pooled magnitude of postpartum modern contraception utilization in Ethiopia was 45.79% (95%CI 36.45%, 55.13%). The review found that having more than four Antenatal care visits(ANC), having postnatal care visit (PNC), having a formal education, history of family planning use, history of counseling on family planning, and having greater than four alive children as significant determinants of postpartum modern contraception utilization.

CONCLUSION

The magnitude of postpartum modern contraception utilization in Ethiopia was low. ANC visit, PNC visit, maternal educational status, history of previous family planning use, counseling on family planning, and number of alive children were found to be significant determinants of postpartum modern contraception utilization. Therefore, strengthening focused ANC and PNC services to encourage women in utilizing modern contraception during the postnatal period is needed.

Patterns and determinants of modern contraceptive discontinuation among women of reproductive age: Analysis of Kenya Demographic Health Surveys, 2003-2014

Objectives

This study aimed to examine patterns and determinants of modern contraceptive discontinuation among women in Kenya.

Methods

Secondary analysis was conducted using national representative Kenya Demographic and Health Surveys of 2003, 2008/9, and 2014. These household cross-sectional surveys targeted women of reproductive age from 15 to 49 years who had experienced an episode of modern contraceptive use within five years preceding the surveys from 2003 (n = 2686), 2008/9 (n = 2992), and 2014 (5919). The contraceptive discontinuation rate was defined as the number of episodes discontinued divided by the total number of episodes. Weighted descriptive statistics, multivariable logistic regression analysis, and Cox proportional hazards analysis were used to examine the determinants of contraceptive discontinuation.

Results

The 12-month contraceptive discontinuation rate for all methods declined from 37.5% in 2003 and 36.7% in 2008/9 to 30.5% in 2014. Consistently across the three surveys, intrauterine devices had the lowest 12-month discontinuation rate (6.4% in 2014) followed by implants (8.0%, in 2014). In 2014, higher rates were seen for pills (44.9%) and male condoms (42.9%). The determinants of contraceptive discontinuation among women of reproductive age in the 2003 survey included users of short-term contraception methods, specifically for those who used male condoms (hazard ratio [HR] = 3.30, 95% confidence interval [CI] = 2.13–5.11) and pills (HR = 2.68; 95CI = 1.79–4.00); and younger women aged 15–19 year (HR = 2.07; 95% CI = 1.49–2.87) and 20–24 years (HR = 1.94; 95% CI = 1.61–2.35). The trends in the most common reasons for discontinuation from 2003 to 2014 revealed an increase among those reporting side effects (p = 0.0002) and those wanting a more effective method (p<0.0001). A decrease was noted among those indicating method failure (p<0.0001) and husband disapproval (p<0.0001).

Conclusions

Family planning programs should focus on improving service quality to strengthen the continuation of contraceptive use among those in need. Women should be informed about potential side effects and reassured on health concerns, including being provided options for method switching. The health system should avail a wider range of contraceptive methods and ensure a constant supply of commodities for women to choose from. Short-term contraceptive method users and younger women may need greater support for continued use.

Mental health impact on the unmet need for family planning and fertility rate in rural Ethiopia: a population-based cohort study

AIMS

Although much research has focused on socio-demographic determinants of uptake of contraception, few have studied the impact of poor mental health on women's reproductive behaviours. The aim of this study was to examine the impact of poor mental health on women's unmet need for contraception and fertility rate in a low-income country setting.

METHODS

A population-based cohort of 1026 women recruited in their third trimester of pregnancy in the Butajira district in rural Ethiopia was assessed for symptoms of antenatal common mental disorders (CMDs; depression and anxiety) using Self-Reporting Questionnaire-20. Women were followed up regularly until 6.5 years postnatal (between 2005 and 2012). We calculated unmet need for contraception at 1 year (n = 999), 2.5 (n = 971) and 3.5 years (n = 951) post-delivery of index child and number of pregnancies during study period. We tested the association between CMD symptoms, unmet need for contraception and fertility rate.

RESULTS

Less than one-third of women reported current use of contraception at each time point. Unmet need for birth spacing was higher at 1 year postnatal, with over half of women (53.8%) not using contraception wanting to wait 2 or more years before becoming pregnant. Higher CMD symptoms 1 year post-index pregnancy were associated with unmet need for contraception at 2.5 years postnatal in the unadjusted [odds ratio (OR) 1.09; 95% confidence interval (CI) 1.04-1.15] and fully adjusted model [OR 1.06; 95% CI 1.01-1.12]. During the 6.5 year cohort follow-up period, the mean number of pregnancies per woman was 2.4 (s.d. 0.98). There was no prospective association between maternal CMD and number of pregnancies in the follow-up period.

CONCLUSIONS

CMD symptoms are associated with increased unmet need for family planning in this cohort of women with high fertility and low contraceptive use in rural Ethiopia. There is a lack of models of care promoting integration of mental and physical health in the family planning setting and further research is necessary to study the burden of preconception mental health conditions and how these can be best addressed.

Share of current unmet need for modern contraceptive methods attributed to past users of these methods in India

Despite persistent efforts, unmet need for contraceptives in India has declined only slightly from 14% to 13% between 2005-06 and 2015-16. Many women using a family planning method discontinue it without switching to another method and continue to have unmet need. This study quantified the share of current unmet need for modern contraceptive methods attributed to past users of these methods in India. Data were drawn from two rounds of the National Family Health Survey conducted in 2005-06 and 2015-16. Using information on women with current unmet need, and whether they used any modern method in the past, the share of past users with current unmet need for modern methods was calculated. Bivariate and multivariate analyses were performed. Among 46 million women with unmet need, 11 million were past users of modern methods in 2015-16. The share of current unmet need attributed to past users of modern contraceptive methods declined from 27% in 2005-06 to 24% in 2015-16. Share of current unmet need attributed to past users was associated with reversible method use. This share rose with increased use of modern reversible methods. With the Indian family planning programme's focus on increasing modern reversible method use, the share of unmet need attributed to past users of modern methods is likely to increase in the future. The programme's emphasis on continuation of contraceptive use, along with bringing in new users, could be one of the key strategies for India to achieve the FP2020 goals.

Contraceptive Autonomy: Conceptions and Measurement of a Novel Family Planning Indicator

Since the 1994 International Conference on Population and Development, there has been increased attention to high-quality and rights-based family planning, but these concepts have been difficult to measure. Perhaps due to an intellectual history intertwined with population control, contemporary family planning programs and researchers often use (modern) method use as a primary marker of success, with indicators focusing narrowly on contraceptive use and fertility. This results in a fundamental misalignment between existing metrics and the stated family planning goals of promoting reproductive health and rights. This report describes the rationale for a novel family planning indicator called "contraceptive autonomy" and proposes a methodology for measuring this concept at the population level. Defining contraceptive autonomy as the factors necessary for a person to decide for themself what they want in relation to contraception and then to realize that decision, this indicator divides the contraceptive autonomy construct into subdomains of informed choice, full choice, and free choice. By acknowledging that autonomous nonuse is a positive outcome,aiming to maximize contraceptive autonomy rather than use could help shift incentives for family planning programs and reduce some common forms of contraceptive coercion, as our measurement approach is realigned with our focus on high-quality rights-based care.

Family planning science and practice lessons from the 2018 International Conference on Family Planning

Since 2009, the International Conference on Family Planning (ICFP) has served as an opportunity for the global reproductive health community to share FP advances and practice lessons in the areas of research, programming, and advocacy. The key takeaways from all 15 tracks were grouped into six thematic areas: 1) Investing in family planning for a lifetime of returns. FP may yield different health and monetary benefits but continues to face a shortage of funding, although locally owned models provide alternative financing solutions. 2) Addressing inequities in family planning for adolescents, youth, and key populations. Marginalized populations and youth still face challenges in accessing FP. Youth-inclusive and user-centered programming show promise in addressing such challenges. 3) Reproductive justice: Abortion care, family planning, and women’s wellbeing. Unsafe abortions tend to be more common among younger, poor, uneducated and rural women. Promising evidence show that providers may effectively shift from unsafe practices of dilation and curettage to safer manual vacuum aspiration or misoprostol. 4) Couple dynamics and family planning decision-making. Couples who share everyday life decision-making are more likely to use contraceptives; couple discordance on childbearing and fertility decisions directly influence women’s decisions to covertly use FP. 5) Male involvement in FP programming. Male champions and advocates can successfully promote couple uptake of FP. Gender-transformative programming promotes gender equity and can directly impact behavior change. 6) Breakthroughs in novel contraceptives and systems improvement in family planning. User-centered contraceptive technologies and information systems present an opportunity to facilitate self-care and optimal supply chain management. ICFP 2018 highlighted research advances, implementation science wins, and critical knowledge gaps in global FP access and use. More research is needed to determine the scalability of novel technologies, more effective programming and service delivery models to ensure multisectoral knowledge translation and utilization by policymakers.

Measures of family planning service quality associated with contraceptive discontinuation: an analysis of Measurement, Learning & Evaluation (MLE) project data from urban Kenya

Introduction: Several measures to assess family planning service quality (FPQ) exist, yet there is limited evidence on their association with contraceptive discontinuation. Using data from the Measurement, Learning & Evaluation (MLE) Project, this study investigates the association between FPQ and discontinuation-while-in-need without switching in five cities in Kenya. Two measures of FPQ are examined - the Method Information Index (MII) and a comprehensive service delivery point (SDP) assessment rooted in the Bruce Framework for FPQ. Methods: Three models were constructed: two to assess MII reported in household interviews (as an ordinal and binary variable) among 1,033 FP users, and one for facility-level quality domains among 938 FP users who could be linked to a facility type included in the SDP assessment. Cox proportional hazards ratios were estimated where the event of interest was discontinuation-while-in-need without switching. Facility-level FPQ domains were identified using exploratory factor analysis (EFA) using SDP assessment data from 124 facilities. Results: A woman's likelihood of discontinuation-while-in-need was approximately halved whether she was informed of one aspect of MII (HR: 0.45, p < 0.05), or all three (HR: 0.51, p < 0.01) versus receiving no information, when MII was assessed as an ordinal variable. Six facility-level quality domains were identified in EFA. Higher scores in information exchange, privacy, autonomy & dignity and technical competence were associated with a reduced risk of discontinuation-while-in-need (p < 0.05). Conclusions: The MII has potential as an actionable metric for FPQ monitoring at the health facility level. Furthermore, family planning facilities and programs should emphasize information provision and client-centered approaches to care alongside technical competence in the provision of FP care.

Quality of Family Planning Counseling in Ethiopia: Trends and determinants of information received by female modern contraceptive users, evidence from national survey data, (2014- 2018)

BACKGROUND

Family planning counseling is critical for women to make informed reproductive and sexual health decisions. Despite Ethiopia's success in expanding access to family planning services, information on the quality of family planning counseling is limited. The objectives of this study were to assess whether the quality of counseling from the female client´s perspective has changed over time (2014 to 2018) and to investigate determinants associated with the quality of counseling to provide a more nuanced understanding of disparities in sexual and reproductive health outcomes in Ethiopia.

METHODS

Data were obtained from five rounds of the Ethiopian Performance Monitoring and Accountability 2020 female survey questionnaire. Quality of counseling was categorized into four levels based on the responses of the questions that compose the Method Information Index, a core Family Planning 2020 indicator that serves as a proxy for quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The proportion of female contraceptive users that received good counseling were examined over time by each region, demographic characteristics, and contraception method type and source. Ordinal logistic regression was applied to the last survey round (2018) to investigate determinants associated with counseling quality.

RESULTS

The proportion of female contraception users that reported receiving information on all three questions did not significantly change over the period 2014 to 2018. Overall quality of counseling on family planning was low, with only 30% of women reporting receiving sufficient information during counseling. The likelihood of good quality counseling was the least among those who had no formal schooling when compared to those who had higher educational attainment (OR = 0.70, 95% CI: 0.50, 0.97). Women from the wealthiest quintile were 1.72 times more likely (95% CI: 1.10, 2.69) to receive good quality counseling when compared to women in the lower wealth quintile. Women from rural areas were 1.51 times more likely to have received good counseling when compared to those in urban areas (95% CI: 1.04, 2.18). Amhara residents were less likely to receive good counseling when compared to the SNNPR (OR: 0.51, 95% CI: 0.32, 0.81). Women who acquired their method from the private sector had worse counseling (OR: 0.31, 95% CI: 0.23, 0.41) when compared to the public sector. Those using short-acting methods were more at risk of receiving lesser quality counseling when compared to users of long-acting methods (OR: 0.58, 95% CI: 0.46, 0.72).

CONCLUSION

The results of this analysis indicated that Ethiopia's overall progress in modern contraceptive use has not been accompanied by a corresponding increase in the quality of family planning counseling. Improving the quality of contraception counseling for women across all demographics, including wealth quintiles and education, is a crucial strategy to support positive reproductive health outcomes with a rights-based focus. Based on the findings of this study, it is essential to emphasize the need to do proper counseling for all methods including short-acting methods especially for those working the private sector and some of the regions which have lower prevalence of good counseling. Further community-based participatory and qualitative research should focus on understanding the root causes and barriers to the delivery of high-quality counseling in Ethiopia.

Estimating progress towards meeting women's contraceptive needs in 185 countries: A Bayesian hierarchical modelling study

BACKGROUND

Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. Monitoring progress towards these outcomes is well established for women of reproductive age (15-49 years) who are married or in a union (MWRA). For those who are not, limited data and variability in data sources and indicator definitions make monitoring challenging. To our knowledge, this study is the first to provide data and harmonised estimates that enable monitoring for all women of reproductive age (15-49 years) (WRA), including unmarried women (UWRA). We seek to quantify the gaps that remain in meeting family-planning needs among all WRA.

METHODS AND FINDINGS

In a systematic analysis, we compiled a comprehensive dataset of family-planning indicators among WRA from 1,247 nationally representative surveys. We used a Bayesian hierarchical model with country-specific time trends to estimate these indicators, with 95% uncertainty intervals (UIs), for 185 countries. We produced estimates from 1990 to 2019 and projections from 2019 to 2030 of contraceptive prevalence and unmet need for family planning among MWRA, UWRA, and all WRA, taking into account the changing proportions that were married or in a union. The model accounted for differences in the prevalence of sexual activity among UWRA across countries. Among 1.9 billion WRA in 2019, 1.11 billion (95% UI 1.07-1.16) have need for family planning; of those, 842 million (95% UI 800-893) use modern contraception, and 270 million (95% UI 246-301) have unmet need for modern methods. Globally, UWRA represented 15.7% (95% UI 13.4%-19.4%) of all modern contraceptive users and 16.0% (95% UI 12.9%-22.1%) of women with unmet need for modern methods in 2019. The proportion of the need for family planning satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 75.7% (95% UI 73.2%-78.0%) globally, yet less than half of the need for family planning was met in Middle and Western Africa. Projections to 2030 indicate an increase in the number of women with need for family planning to 1.19 billion (95% UI 1.13-1.26) and in the number of women using modern contraception to 918 million (95% UI 840-1,001). The main limitations of the study are as follows: (i) the uncertainty surrounding estimates for countries with little or no data is large; and (ii) although some adjustments were made, underreporting of contraceptive use and needs is likely, especially among UWRA.

CONCLUSIONS

In this study, we observed that large gaps remain in meeting family-planning needs. The projected increase in the number of women with need for family planning will create challenges to expand family-planning services fast enough to fulfil the growing need. Monitoring of family-planning indicators for all women, not just MWRA, is essential for accurately monitoring progress towards universal access to sexual and reproductive healthcare services-including family planning-by 2030 in the SDG era with its emphasis on 'leaving no one behind.'

Sub-national levels and trends in contraceptive prevalence, unmet need, and demand for family planning in Nigeria with survey uncertainty

Background

Ambitious global goals have been established to provide universal access to affordable modern contraceptive methods. To measure progress toward such goals in populous countries like Nigeria, it’s essential to characterize the current levels and trends of family planning (FP) indicators such as unmet need and modern contraceptive prevalence rates (mCPR). Moreover, the substantial heterogeneity across Nigeria and scale of programmatic implementation requires a sub-national resolution of these FP indicators. The aim of this study is to estimate the levels and trends of FP indicators at a subnational scale in Nigeria utilizing all available data and accounting for survey design and uncertainty.

Methods

We utilized all available cross-sectional survey data from Nigeria including the Demographic and Health Surveys, Multiple Indicator Cluster Surveys, National Nutrition and Health Surveys, and Performance, Monitoring, and Accountability 2020. We developed a hierarchical Bayesian model that incorporates all of the individual level data from each survey instrument, accounts for survey uncertainty, leverages spatio-temporal smoothing, and produces probabilistic estimates with uncertainty intervals.

Results

We estimate that overall rates and trends of mCPR and unmet need have remained low in Nigeria: the average annual rate of change for mCPR by state is 0.5% (0.4%,0.6%) from 2012-2017. Unmet need by age-parity demographic groups varied significantly across Nigeria; parous women express much higher rates of unmet need than nulliparous women.

Conclusions

Understanding the estimates and trends of FP indicators at a subnational resolution in Nigeria is integral to inform programmatic decision-making. We identify age-parity-state subgroups with large rates of unmet need. We also find conflicting trends by survey instrument across a number of states. Our model-based estimates highlight these inconsistencies, attempt to reconcile the direct survey estimates, and provide uncertainty intervals to enable interpretation of model and survey estimates for decision-making.

Standardizing Measurement of Contraceptive Use Among Unmarried Women

Historically, the family planning practices and needs of married women have been monitored and reported uniformly. However, the same uniformity does not hold for unmarried women. Because key data and information platforms employ different measurement approaches-namely, different definitions of sexual recency-reports of contraceptive prevalence and unmet need among unmarried women are inconsistent. We examine how the measurement approaches employed by 3 large organizations yield such divergent estimates. We find that contraceptive prevalence and unmet need estimates among married women do not vary much by sexual recency. For unmarried women, contraceptive prevalence is systematically lower and unmet need is systematically higher as the sexual recency window widens. In the short term, we recommend using the 1-month cutoff as analyses reveal it yields the most precise estimates for better recognizing the needs of this important demographic group.

Capitalising on shared goals for family planning: a concordance assessment of two global initiatives using longitudinal statistical models

OBJECTIVE

Family planning is unique among health interventions in its breadth of health, development and economic benefits. The complexity of formulating effective strategies to promote women's and girls' access to family planning calls for closer coordination of resources and attention from all stakeholders. Our objective was to quantify the concordance of two global initiatives: Family Planning 2020's adding 120 million modern contraceptive users by 2020 (proposed during The London Summit 2012 by Gates Foundation) and satisfying the 75% demand for modern contraceptives by 2030 (proposed by United States Agency for International Development). A demonstration of their concordance, or lack thereof, provides an understanding of the proposed quantitative goals and helps to formulate collective strategies.

DESIGN AND SETTING

We applied fixed effects longitudinal models to assess the convergence of the two initiatives. The implications of success in one initiative on achieving the other are simulated to illustrate their shared goals. Publicly available data on contraceptive use, unmet need and met need from national surveys are used. Extensive model validations were conducted to check and confirm models' predictive performance.

RESULTS

Our results show that the 75% demand satisfied initiative will reach 82 million additional modern users by 2020 and 120 million by early 2023. Following FP2020's proposed annual increase of modern contraceptive use, 9 of the 41 commitment-making countries will reach the 75% target by 2020; another 8 countries will do so by 2030. Extending FP2020's proposed contraceptive growth to 2030 implies the achievement of the 75% target in less than half (17) of the 41 commitment-making countries.

CONCLUSION

The results from the statistical exercise demonstrate that the two global initiatives move toward the same goal of promoting access to family planning and overall both are ambitious. Closer coordination between major stakeholders in international family planning may stimulate more efficient mobilisation and utilisation of global sources, which is urgently needed to accelerate the progress toward satisfying women's need for family planning.

Intention to use long-acting and permanent contraceptive methods and associated factors in health institutions of Aksum Town, North Ethiopia

Objective

In Ethiopia, the majority of married women practice predominantly short-acting contraceptive methods. Therefore this study aims to assess intention to use LAPMs and its determinants among short-acting users in Health Institutions of Aksum Town, North Ethiopia.

Results

Prevalence of intention to use LAPMs was 52.1% (95% CI 47.4–57.0). Good knowledge on LAPMs [AOR = 2.15; 95% CI (1.29, 3.56)], positive attitude towards LAPMs [AOR = 3.41; 95% CI (1.99, 5.85)], 18–24 years of age [AOR = 3.18; 95% CI (1.30, 7.79)], being primary school in educational level [AOR = 0.34; 95% CI (0.14, 0.78)], decision on the number of children jointly with partner [AOR = 2.05; 95% CI (1.01, 4.18)], having more than two children [AOR = 10.67; 95% CI (1.29, 88.31)], and no [AOR = 10.21; 95% CI (3.10, 33.58)] and one [AOR = 4.70; 95% CI (1.68, 13.13)] extra number of children desired were factors significantly associated with having intention to use LAPMs compared to their counterparts. The intention to use LAPMs was low. Therefore, appropriate information, education and communication strategies must be designed to raise awareness and change the negative attitude of the community on LAPMs.

Impact of the village health center project on contraceptive behaviors in rural Jordan: a quasi-experimental difference-in-differences analysis

Background

Appropriate contraceptive use remains a major health challenge in rural Jordan. The Japan International Cooperation Agency implemented a project aimed at enhancing the capacity of village health centers (VHCs) to improve the quality and quantity of family planning (FP) services in rural Jordan in 2016–2018. Facility- and community-based approaches were integrated into the interventions. We evaluated the project’s impacts on contraceptive behaviors and the effectiveness of the two approaches.

Methods

We used a difference-in-differences analysis based on the project baseline and endline surveys, and logistic regression analysis to assess associations between eight primary outcomes and three secondary outcomes (impacts). The unit of intervention was five target VHCs; the unit of analysis was currently married women of reproductive age (15–49 years) in five intervention and five control villages.

Results

Overall, 2061 married women participated; 83.8% were in need of FP. Compared with the control villages, significant effects, ranging from + 0.4% points (pp) to + 11.5 pp., were observed in the intervention villages for six primary outcomes in these categories: increasing the use of FP services at VHCs, participation in health promotion activities, and changing the sources of reproductive health information. There was a trend toward improved secondary outcomes in the intervention villages, but no significant differences were observed between the intervention and control villages regarding modern contraceptive use (mCU; + 4.3 pp), traditional contraceptive use (tCU; − 0.5 pp), and spousal agreement on contraception (+ 5.1 pp). mCU was positively associated with five primary outcomes: obtaining contraceptives at VHCs [adjusted odds ratio (AOR) 3.44, 95% confidence interval (CI) 1.26–9.40], education sessions at VHC (AOR 7.41, 95% CI 1.60–34.39), health activities in communities (AOR 7.41, 95% CI 3.28–16.78), counseling by private doctor/clinic (AOR 0.62, 95% CI 0.40–0.97), and information gained through TV (AOR 0.50, 95% CI 0.32–0.76). Spousal agreement on contraception showed similar positive trends. tCU was associated only with TV.

Conclusions

The project had impacts on increased mCU and husbands’ perception of contraception in rural Jordan. The integration of facility- and community-based approaches may be effective in shifting from tCU to mCU in other rural areas.

Reasons for nonuse of contraceptive methods by women with demand for contraception not satisfied: an assessment of low and middle-income countries using demographic and health surveys

Background

Nonuse of contraceptive methods by women in need of contraception may impact their sexual and reproductive health. The aim of this study was to describe the reasons for nonuse of contraception among women with demand for contraception not satisfied in low and middle-income countries (considering both overall countries and various subgroups of women).

Methods

We used the latest Demographic and Health Survey data from 47 countries. A descriptive analysis of the reasons for nonuse of contraceptive methods was performed among sexually active women with demand for contraception not satisfied. The prevalence of each reported reason was also evaluated according to marital status, woman’s age and schooling, area of residence, wealth index, and parity. Wealth-related absolute inequality for each reason was also evaluated using the Slope Index of Inequality. A pro-rich inequality pattern means that the reason is more prevalent among the richest women while a pro-poor means the reason is more common among the poorest ones.

Results

On average, 40.9% of women in need of contraception were not using any contraceptive methods to avoid pregnancy. Overall, the most prevalent reasons for nonuse of contraceptives were “health concerns” and “infrequent sex,” but the prevalence of each reason varied substantially across countries. Nonuse due to “opposition from others” was higher among married than unmarried women; in turn, the prevalence of nonuse due to “lack of access” or “lack of knowledge” was about two times higher in rural areas than in urban areas. Women with less schooling more often reported nonuse due to “lack of access.” Pro-rich inequality was detected for reasons “health concerns,” “infrequent sex,” and “method-related”, while the reasons “other opposed,” “fatalistic,” “lack of access,” and “lack of knowledge” were linked to patterns of pro-poor inequality.

Conclusions

Family planning promotion policies must take into account the different reasons for the nonuse of contraceptive methods identified in each country as well as the contextual differences regarding women of reproductive age (such as social norms and barriers that prevent women from accessing and using contraceptives).

"I was obligated to accept": A qualitative exploration of contraceptive coercion

Despite narratives about empowering women through contraception, global family planning programs are evaluated primarily by their ability to increase contraceptive uptake and reduce fertility in the developing world. Some scholars have raised concerns that this emphasis on fertility reduction and contraceptive uptake may contribute to situations where women are coerced into adopting contraceptive services they do not fully understand or want. Yet surprisingly little data have been collected to investigate whether such coercion exists or how it might manifest. In-depth interviews with 49 women of reproductive age in a sub-Saharan African country begin to fill this knowledge gap. Respondents reported a range of non-autonomous experiences including biased or directive counseling, dramatically limited contraceptive method mix, scare tactics, provision of false medical information, refusal to remove provider-dependent methods, and the non-consented provision of long-acting methods. The results show that, rather than a binary outcome, coercion sits on a spectrum and need not involve overt force or violence, but can also result from more quotidian limits to free, full, and informed choice. The study finds that global family planning policies and discourses do appear to incentivize coercive practices. It also calls into question the central role of intentionality, by demonstrating how coercion can arise from structural causes as well as interpersonal ones. By showing how contraceptive autonomy may be limited even by providers working in good faith, these results argue for an end to the instrumentalization of women's bodies, and for a radical reconceptualization of family planning goals and measurements to focus exclusively on reproductive health, rights and justice.

Global implementation of PrEP for HIV prevention: setting expectations for impact

INTRODUCTION

Questions remain whether HIV pre-exposure prophylaxis (PrEP) can be translated into a successful public health intervention, leading to a decrease in population-level HIV incidence. We use examples from HIV treatment and contraceptives to discuss expectations for PrEP uptake, adherence, and persistence and their combined impact on the epidemic.

DISCUSSION

Targets for PrEP uptake must be based on the local HIV epidemic and will depend on appropriate estimates of the key populations at risk for HIV. However, there is evidence that targets, once established, can successfully be met and that uptake may increase with awareness. Messaging around adherence should include that daily adherence is the goal (except for those MSM for whom event-driven dosing is a good fit), but perfect adherence should not be a barrier. Ideally, clients persist on PrEP for as long as they are at risk for HIV. While PrEP will be most effective when coverage is focused on high-risk populations, normalizing rather than stigmatizing PrEP will be highly beneficial.

CONCLUSIONS

While many challenges to PrEP implementation exist, we focused on the three key steps of uptake, adherence and persistence as measurable processes that can lead to improved coverage and decreased HIV incidence.

Do Indian women receive adequate information about contraception?

This study analysed the recent changes and patterns of information received about contraceptive methods by contraceptive users in India - an important indicator of quality of care in family planning services. Data were taken from the third and fourth rounds of National Family and Health Surveys (NFHS) conducted in India during 2005-06 and 2015-16. The Method Information Index (MII) was used to capture the information received by respondents on three aspects of contraceptive method use: information about the side-effects of the method, what to do if they experienced any complication from using the method and information received about other methods of contraception. A separate analysis of information received by users about the permanency of sterilization was also carried out. Logistic regression models were applied to assess the independent effects of users' background characteristics and their states and union territories of residence on method information received by them. The value of the MII nearly doubled from about 16% in 2004-05 to 31% in 2015-16, indicating a marked increase in the information received by contraceptive users in India over the period between 2005-06 and 2015-16. In addition, the percentage of sterilized women who received information about the permanency of the method also increased, from 67% to 80%, over the period. While considerable progress has been made in the last decade, there is still plenty of scope for improvement in the information received by contraceptive users to advance a voluntary approach to family planning.

The Extent to Which Performance-Based Financing Programs' Operations Manuals Reflect Rights-Based Principles: Implications for Family Planning Services

Rights principles should be prioritized and more clearly stated in performance-based financing (PBF) guidance and operational documents. Additional research, including development of validated measurement metrics, is needed to help PBF programs systematically align with rights-based approaches to health care including family planning.

Recognition is growing that development programs need to be guided by rights as well as to promote, protect, and fulfill them. Drawing from a content analysis of performance-based financing (PBF) implementation manuals, we quantify the extent to which these manuals use a rights perspective to frame family planning services. PBF is an adaptable service purchasing strategy that aims to improve equity and quality of health service provision. PBF can contribute toward achieving global family planning goals and has institutional support from multiple development partners including the Global Financing Facility in support of Every Woman Every Child. A review of 23 PBF implementation manuals finds that all documents are focused largely on the implementation of quality and accountability mechanisms, but few address issues of accessibility, availability, informed choice, acceptability, and/or nondiscrimination and equity. Notably, operational inclusion of agency, autonomy, empowerment, and/or voluntarism of health care clients is absent. Based on these findings, we argue that current PBF programs incorporate some mention of rights but are not systematically aligned with a rights-based approach. If PBF programs better reflected the importance of client-centered, rights-based programming, program performance could be improved and risk of infringing rights could be reduced. Given the mixed evidence for PBF benefits and the risk of perverse incentives in earlier PBF programs that were not aligned with rights-based approaches, we argue that greater attention to the rights principles of acceptability, accessibility, availability, and quality; accountability; agency and empowerment; equity and nondiscrimination; informed choice and decision making; participation; and privacy and confidentiality would improve health service delivery and health system performance for all stakeholders with clients at the center. Based on this review, we recommend making the rights-based approach explicit in PBF; progressively operationalizing rights, drawing from local experience; validating rights-based metrics to address measurement gaps; and recognizing the economic value of aligning PBF with rights principles. Such recommendations anchor an aspirational rights agenda with a practical PBF strategy on the need and opportunity for validated metrics.

Trends in contraceptive prevalence rates in sub-Saharan Africa since the 2012 London Summit on Family Planning: results from repeated cross-sectional surveys

Background

The Family Planning 2020 (FP2020) initiative, launched at the 2012 London Summit on Family Planning, aims to enable 120 million additional women to use modern contraceptive methods by 2020 in the world's 69 poorest countries. It will require almost doubling the pre-2012 annual growth rate of modern contraceptive prevalence rates from an estimated 0·7 to 1·4 percentage points to achieve the goal. We examined the post-Summit trends in modern contraceptive prevalence rates in nine settings in eight sub-Saharan African countries (Burkina Faso; Kinshasa, DR Congo; Ethiopia; Ghana; Kenya; Niamey, Niger; Kaduna, Nigeria; Lagos, Nigeria; and Uganda). These settings represent almost 73% of the population of the 18 initial FP2020 commitment countries in the region.

Methods

We used data from 45 rounds of the Performance Monitoring and Accountability 2020 (PMA2020) surveys, which were all undertaken after 2012, to ascertain the trends in modern contraceptive prevalence rates among all women aged 15–49 years and all similarly aged women who were married or cohabitating. The analyses were done at the national level in five countries (Burkina Faso, Ethiopia, Ghana, Kenya, and Uganda) and in selected high populous regions for three countries (DR Congo, Niger, and Nigeria). We included the following as modern contraceptive methods: oral pills, intrauterine devices, injectables, male and female sterilisations, implants, condom, lactational amenorrhea method, vaginal barrier methods, emergency contraception, and standard days method. We fitted design-based linear and quadratic logistic regression models and estimated the annual rate of changes in modern contraceptive prevalence rates for each country setting from the average marginal effects of the fitted models (expressed in absolute percentage points). Additionally, we did a random-effects meta-analysis to summarise the overall results for the PMA2020 countries.

Findings

The annual rates of changes in modern contraceptive prevalence rates among all women of reproductive age (15–49 years) varied from as low as 0·77 percentage points (95% CI −0·73 to 2·28) in Lagos, Nigeria, to 3·64 percentage points (2·81 to 4·47) in Ghana, according to the quadratic model. The rate of change was also high (>1·4 percentage points) in Burkina Faso, Kinshasa (DR Congo), Kaduna (Nigeria), and Uganda. Although contraceptive use was rising rapidly in Ethiopia during the pre-Summit period, our results suggested that the yearly growth rate stalled recently (0·92 percentage points, 95% CI −0·23 to 2·07) according to the linear model. From the meta-analysis, the overall weighted average annual rate of change in modern contraceptive prevalence rates in all women across all nine settings was 1·92 percentage points (95% CI 1·14 to 2·70). Among married or cohabitating women, the annual rates of change were higher in most settings, and the overall weighted average was 2·25 percentage points (95% CI 1·37–3·13).

Interpretations

Overall, the annual growth rates exceeded the 1·4 percentage points needed to achieve the FP2020 goal of 120 million additional users of modern contraceptives by 2020 in the select study settings. Local programme experiences can be studied for lessons to be shared with other countries aiming to respond to unmet demands for family planning. The findings of this study have implications for the way progress is tracked toward achieving the FP2020 goal.

Funding

The Bill & Melinda Gates Foundation.