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Sarnak D, Anglewicz P, Ahmed S. Unmet need and intention to use as predictors of adoption of contraception in 10 Performance Monitoring for Action geographies. SSM Popul Health 2023; 22:101365. [PMID: 36909928 PMCID: PMC9996096 DOI: 10.1016/j.ssmph.2023.101365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 01/17/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
The determinants of fertility typically feature demand as the key motivation driver for contraceptive use. Yet relatively little is known about the extent to which demand for contraception predicts future contraceptive use, primarily due to the lack of longitudinal data that captures these measures at different time points. Two ways in which demand is often measured are unmet need and intention to use. Despite its intended use as a population measure, unmet need is commonly used in individual-level analyses and as a marker for individual-level demand for contraception. Few studies have assessed the extent to which unmet need predicts or reflects women's true latent demand as demonstrated by their future contraceptive use; the same is true for intention to use contraception in the future. We expand on previous research to assess whether and the degree to which unmet need and intention to use contraception predict adoption of contraception within a year, among nonusers in ten representative geographies using Performance Monitoring for Action (PMA) data. Findings show that in nine of ten sites, intention to use within a year was significantly associated with subsequent adoption, while in eight of ten sites, unmet need for spacing or limiting was not associated with adoption. Our results are important for programs as they try to identify true dynamic demand for contraception.
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Affiliation(s)
- Dana Sarnak
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Phil Anglewicz
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
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Senderowicz L, Bullington BW, Sawadogo N, Tumlinson K, Langer A, Soura A, Zabre P, Sie A. Assessing the Suitability of Unmet Need as a Proxy for Access to Contraception and Desire to Use It. Stud Fam Plann 2023; 54:231-250. [PMID: 36841972 PMCID: PMC10257191 DOI: 10.1111/sifp.12233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Unmet need for contraception is a widely used but frequently misunderstood indicator. Although calculated from measures of pregnancy intention and current contraceptive use, unmet need is commonly used as a proxy measure for (1) lack of access to contraception and (2) desire to use it. Using data from a survey in Burkina Faso, we examine the extent to which unmet need corresponds with and diverges from these two concepts, calculating sensitivity, specificity, and positive/negative predictive values. Among women assigned conventional unmet need, 67 percent report no desire to use contraception and 61 percent report access to a broad range of affordable contraceptives. Results show unmet need has low sensitivity and specificity in differentiating those who lack access and/or who desire to use a method from those who do not. These findings suggest that unmet need is of limited utility to inform family planning programs and may be leading stakeholders to overestimate the proportion of women in need of expanded family planning services. We conclude that more direct measures are feasible at the population level, rendering the proxy measure of unmet need unnecessary. Where access to and/or desire for contraception are the true outcomes of interest, more direct measures should be used.
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Affiliation(s)
- Leigh Senderowicz
- Department of Gender and Women’s Studies, University of Wisconsin-Madison, USA
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, USA
| | - Brooke W. Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, USA
| | - Nathalie Sawadogo
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Burkina Faso
| | - Katherine Tumlinson
- Carolina Population Center, University of North Carolina at Chapel Hill, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Ana Langer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, USA
| | - Abdramane Soura
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Burkina Faso
| | - Pascal Zabre
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | - Ali Sie
- Centre de Recherche en Santé de Nouna, Burkina Faso
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Bingenheimer JB, Hardee K, Hindin M, Jain A, Mumah J, Dam JV. Introduction to the Special Issue: Indicators in Sexual and Reproductive Health and Rights. Stud Fam Plann 2023; 54:9-16. [PMID: 36939037 DOI: 10.1111/sifp.12239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Affiliation(s)
| | | | | | - Aparna Jain
- Senior Director, Making Cents International & Chief of Party, CARE-GBV
| | - Joyce Mumah
- Technical Lead, Monitoring and Evaluation - WISH2ACTION, International Planned Parenthood Federation
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Senderowicz L, Maloney N. Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs. POPULATION AND DEVELOPMENT REVIEW 2022; 48:689-722. [PMID: 36578790 PMCID: PMC9793870 DOI: 10.1111/padr.12478] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Leigh Senderowicz
- Leigh Senderowicz is Health Disparities Research Scholar, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, Wisconsin, USA and Postdoctoral Affiliate, Center for Demography and Ecology, University of Wisconsin-Madison, Madison, Wisconsin, USA. Nicole Maloney is an alumna of the Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Nicole Maloney
- Leigh Senderowicz is Health Disparities Research Scholar, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, Wisconsin, USA and Postdoctoral Affiliate, Center for Demography and Ecology, University of Wisconsin-Madison, Madison, Wisconsin, USA. Nicole Maloney is an alumna of the Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Bell SO, Larson E, Wood SN. Let's Talk About Sex: Improving Measurement of Contraceptive Use in Cross-Sectional Surveys by Accounting for Sexual Activity Recency. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00597. [PMID: 35487552 PMCID: PMC9053161 DOI: 10.9745/ghsp-d-21-00597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022]
Abstract
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.”
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Elizabeth Larson
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Speizer IS, Bremner J, Farid S. Language and Measurement of Contraceptive Need and Making These Indicators More Meaningful for Measuring Fertility Intentions of Women and Girls. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100450. [PMID: 35294385 PMCID: PMC8885354 DOI: 10.9745/ghsp-d-21-00450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 01/05/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ilene S Speizer
- Department of Maternal and Child Health and Carolina Population Center, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.
| | | | - Shiza Farid
- FP2030, Washington DC, USA
- Avenir Health, Washington, DC, USA
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Abstract
This paper presents an analysis of trends in sexual activity by marital status and age, and their associations with contraceptive use. Understanding levels of, and trends in, sexual activity is important for assessing the needs for family planning services and for analysing commonly used family planning indicators. Data were taken from 220 Demographic and Health Surveys (DHSs) and 62 Multiple Indicator Cluster Surveys (MICSs) to provide insights into sexual activity by marital status and age in a total of 94 countries in different regions of the world. The results show the sensitivity of the indicator with respect to the definition of currently sexually active, based on the timing of last sexual intercourse (during the last 4 weeks, 3 months, or 1 year). Substantial diversity in sexual activity by marital status and age was demonstrated across countries. The proportion of married women reporting recent sexual activity (sexual intercourse during the last 4 weeks) ranged from 50% to 90%. The proportion of unmarried women reporting recent sexual activity did not exceed 50% in any of the 94 countries with available data, but showed substantial regional differences: it appeared to be rare in Asia and extremely varied within Africa, Europe and Latin America and the Caribbean. Among married women, sexual activity did not vary much by age group, while for unmarried women, there was an inverted U-pattern by age, with the youngest age group (15-19 years old) having the lowest proportion sexually active. The proportion of women who reported currently using contraception and reported not being sexually active varied by the contraceptive method used and was overall much greater among unmarried women. The evidence presented in this paper can be used to improve family planning policies and programmes to serve the diverse needs, for example regarding method choice and service provision, of unmarried women.
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Aizire J, Dadabhai S, Taulo F, Makanani B, Gadama L, Sun J, Tsui A, Taha TE. Use of effective family planning methods and frequency of sex among HIV-infected and HIV-uninfected African women. Contracept Reprod Med 2018; 3:10. [PMID: 30002871 PMCID: PMC6036664 DOI: 10.1186/s40834-018-0063-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/26/2018] [Indexed: 11/30/2022] Open
Abstract
Background Frequency of sex, contraceptive use and HIV infection are key determinants of fertility. Use of an effective family planning (EFP) method (injectable, oral, intra-uterine contraceptive device (IUCD), or Norplant) potentially eliminates women’s concerns of unintended pregnancy. We report the association between EFP and frequency of sex among HIV-infected and HIV-uninfected non-pregnant African women. Methods Prospective fertility intentions study nested within a phase 3 randomized double-masked placebo-controlled trial (2003-2005) to treat genital tract infections in HIV-infected and HIV-uninfected non-pregnant women. Enrollment of study participants was stratified by HIV infection status. Data on demographics, family planning and sexual history were obtained at baseline and at 3, 6, 9 and 12 months. Chi square and Wilcoxon Rank-Sum tests were used to compare categorical and continuous variables, respectively. Generalized Estimating Equations method was used to estimate relative risk (RR) of frequent sex (≥ 2 acts/week) among users of different EFP methods (injectable, oral, implant or intra-uterine contraceptive device). Results After adjusting for age, current health status, and fertility intentions, EFP use was significantly associated with frequent sex among HIV-infected women (RR 1.32; 95% Confidence Interval [CI] 1.14-1.52); this association was not statistically significant among HIV-uninfected women (RR 1.10; 95% CI 0.96-1.24). Fertility intentions among HIV-infected, and education among HIV-uninfected womenwere independent predictors of sex frequency. Conclusion These data suggest that the association between EFP use and frequency of sex among women varies by HIV infection status. Service-delivery of diverse EFP methods should be integrated within HIV counseling, testing and treatment facilities. Trial registration Registration number NCT00140764 under the clinicaltrials.gov, first Posted: September 1, 2005, last Update Posted: August 10, 2011.
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Affiliation(s)
- Jim Aizire
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Sufia Dadabhai
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Frank Taulo
- 2Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Bonus Makanani
- 2Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- 2Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jin Sun
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Amy Tsui
- 3Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Taha E Taha
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA.,3Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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