Family planning for urban slums in low- and middle-income countries: a scoping review of interventions/service delivery models and their impact

How migration shapes modern contraceptive use among urban young women: Evidence from six African countries

BACKGROUND

Internal migration is an important part of the transition to adulthood for many young people in sub-Saharan Africa. This study examines how migration, in relation to marriage and parenthood, impacts modern contraceptive use and health facility visits amongst young urban women.

METHODS

We draw on Performance Monitoring for Action (PMA) surveys conducted in Burkina Faso, Côte d'Ivoire, Democratic Republic of Congo, Kenya, Nigeria, and Uganda (2019-2022). Our analysis is unique in being able to adjust for whether women wanted to get pregnant soon. Our sample includes women ages 15-24 years currently residing in urban areas (n = 6,225). We conducted logistic regression models clustered by village level identifier to explore the sequence of life events and the timing of migration in relation to current modern contraceptive use and recent health facility visit, a proxy for engagement with formal health services.

RESULTS

The timing of migration matters more than the sequence of these life events. Young urban women who experienced both migration and a birth, regardless of the order, had increased contraceptive use and recent health facility visit, compared to women who had only experienced one event or neither. Young women who migrated in the past year had 24% lower odds of using a modern method (Odds Ratio = 0.76; 95% confidence interval 0.63, 0.91), adjusting for demographic factors and adjusting for fertility preference (Wanting to get pregnant soon). Having had a birth was highly significant for health facility visit and among women who had had a birth, those who migrated in the last year had lower odds of a recent visit (OR = 0.68, 95% CI 0.41, 0.89). Results suggest an initially disruptive effect of migration.

DISCUSSION

Our results suggest young women who recently migrated to urban areas may need additional support in accessing contraception and formal health services for themselves or their children.

The Urban Environment and Disparities in Sexual and Reproductive Health Outcomes in the Global South: a Scoping Review

By 2050, the Global South will contain three-quarters of the world's urban inhabitants, yet no standardized categorizations of urban areas exist. This makes it challenging to compare sub-groups within cities. Sexual and reproductive health and rights (SRHR) are a critical component of ensuring that populations are healthy and productive, yet SRHR outcomes within and across urban settings vary significantly. A scoping review of the literature (2010-2022) was conducted to describe the current body of evidence on SRHR in urban settings in the Global South, understand disparities, and highlight promising approaches to improving urban SRHR outcomes. A total of 115 studies were identified, most from Kenya (30 articles; 26%), Nigeria (15; 13%), and India (16; 14%), focusing on family planning (56; 49%) and HIV/STIs (43; 37%). Findings suggest significant variation in access to services, and challenges such as gender inequality, safety, and precarious circumstances in employment and housing. Many of the studies (n = 84; 80%) focus on individual-level risks and do not consider how neighborhood environments, concentrated poverty, and social exclusion shape behaviors and norms related to SRHR. Research gaps in uniformly categorizing urban areas and key aspects of the urban environment make it challenging to understand the heterogeneity of urban environments, populations, and SRHR outcomes and compare across studies. Findings from this review may inform the development of holistic programs and policies targeting structural barriers to SRHR in urban environments to ensure services are inclusive, equitably available and accessible, and direct future research to fill identified gaps.

Associations of Urban Residence and Wealth Index With Various Sources of Contraceptives Among Young Women Aged 15-24 Years in 25 Sub-Saharan African Countries

PURPOSE

Appreciating user differences in contraceptive sources is essential for improving contraceptive access and safeguarding an equitable and sustainable future. Therefore, this study explored whether urban residence and individual wealth are associated with where women access contraception (e.g., government, private, or nongovernmental organization provider) and assessed whether these associations are modified by the income level in the respondents' country of residence.

METHODS

We analyzed the cross-sectional data of Demographic Health Surveys conducted between 2009 and 2020 in 25 countries. The final data set included 25,081 young women aged between 15 and 24 years who are using contraceptives. Multinomial logistic regression models were established to assess the associations of our outcome variable, namely, various contraceptive sources, with our main independent variables, namely, urban residence and wealth index. We also assessed the potential effect modification by country income level on the above associations.

RESULTS

We observed obvious urban-rural and rich-poor disparities in odds of using contraceptive sources. Generally, living in urban residences and being wealthy were positively associated with all sources of contraceptives. However, these associations were mostly modified by country income level. People living in urban residences utilized more private sources, especially in low-income (beta coefficient, B = 0.973) and upper-middle-income countries (B = 1.361). Young women in urban areas across all analyzed countries were also more likely to use contraceptives from other sources (B = 0.267). In addition, women from poor households were less likely to use private sources (B = -1.166) and other sources (B = -0.547).

DISCUSSION

Even though young women may prefer private sources of contraceptives due to their confidentiality and flexible hours, these sources carry more benefits for rich and urban young women than for poor and rural women. The differential accessibility and affordability may account for the observed urban-rural and rich-poor disparities in using contraceptive sources, respectively, and the income level of a country is likely to modify such disparities.

Sexual behaviors, contraception use and barriers among adolescents and young adults in rural Haiti

BACKGROUND

Adolescents and young adults (AYAs) in Haiti experience a high unintended pregnancy rate, in part due to unmet contraception needs. Little is known about AYA opinions of and experiences with contraception that may explain remaining gaps in coverage. We aimed to describe barriers and facilitators to contraception use among AYAs in Haiti.

METHODS

We conducted a cross-sectional survey and semi-structured qualitative interviews with a convenience sample of AYA females aged 14-24 in two rural communities in Haiti. The survey and semi-structured interviews assessed demographics, sexual health and pregnancy prevention behaviors and explored contraception opinions and experiences according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control. We used descriptive statistics to report means and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through inductive coding and team debriefing.

RESULTS

Among 200 survey respondents, 94% reported any past vaginal sexual activity, and 43% reported ever being pregnant. A large majority were trying to avoid pregnancy (75%). At last sexual activity, 127 (64%) reported use of any contraceptive method; Among them, condoms were the most common method (80%). Among those with previous condom use, most reported use less than half the time (55%). AYAs were concerned about parental approval of birth control use (42%) and that their friends might think they are looking for sex (29%). About one-third felt uncomfortable going to a clinic to ask for birth control. In interviews, AYAs desired pregnancy prevention but frequently noted concerns about privacy and parental, community and healthcare provider judgement for seeking care for reproductive health needs. AYAs also noted a lack of contraception knowledge, evident by frequent misconceptions and associated fears.

CONCLUSION

Among AYAs in rural Haiti, a large majority were sexually active and desire pregnancy avoidance, but few were using effective contraception due to numerous concerns, including privacy and fear of judgement. Future efforts should address these identified concerns to prevent unintended pregnancy and improve maternal and reproductive health outcomes in this population.

Community-Driven Family Planning in Urban Slums: Results from Rawalpindi, Pakistan

Background

Pakistan's contraceptive prevalence rate (CPR) has remained static (less than 1% annual increase since 2006) due to several demand and supply issues. The Akhter Hameed Khan Foundation implemented a community-driven, demand-generation intervention with complementary supply side family planning (FP) services in a large urban informal settlement in Rawalpindi, Pakistan.

Methods

The intervention recruited local women as outreach workers called Aapis (sisters), who conducted household outreach and provided counseling, contraceptives, and referrals. Program data were used to guide in-program corrections, identify the most willing to use married women of reproductive age (MWRA), and target specific geographic locations. The evaluation compared results from two surveys. The baseline survey included 1485 MWRA while the endline included 1560 MWRA that were sampled using the same methodology. A logit model was used with survey weights and clustered standard errors, to estimate the odds of using a contraceptive method.

Results

CPR in Dhok Hassu increased from 33% at the baseline to 44% at endline. Long-acting reversible contraceptives (LARCs) usage increased from 1% at baseline to 4% at endline. Increase in CPR is correlated with increasing number of children and education of MWRA and is the highest between the ages of 25 and 39 and for working women. Qualitative evaluation of the intervention provided lessons about in-program corrections using data and empowerment of the female outreach workers and MWRA.

Conclusion

The Aapis Initiative is a unique community-based demand-supply side intervention that successfully increased modern contraceptive prevalence rate (mCPR) by economically engaging the women from within the community as outreach workers and enabling healthcare providers to establish a sustainable ecosystem for increasing knowledge and access to family planning services.

Contraceptive Use in Urban Africa: Examining Trends in Rich-Poor Gaps

Previous studies have documented significant differences in health and reproductive health outcomes between the poor and nonpoor across various countries in sub-Saharan Africa. However, a number of these studies is dated, and the past decade has witnessed significant shifts in health and reproductive health outcomes in many African countries. Using recent data from the Demographic and Health Surveys, this paper updates and extends the literature by examining patterns in contraceptive practice among poor and nonpoor married women in urban settings in 19 African countries. First, we analyze changes in the rich-poor gaps in modern contraceptive prevalence (mCP) in urban Africa over time. We then determine the public source of the supply of modern contraceptives to the urban poor and how that supply may have changed over a 10-year period. The findings show that, in most Eastern and Southern African countries, previous gaps in mCP between the rich and poor married women have disappeared. Countries in Central and Western Africa, however, continue to have significant gaps in mCP between rich and poor women, with urban poor women experiencing only a modest improvement in mCP over the past decade. This paper contributes to our understanding about sub-regional dynamics in reproductive health outcomes in urban settings in sub-Saharan Africa.

Evaluation of a gender synchronized family planning intervention for married couples in rural India: The CHARM2 cluster randomized control trial

BACKGROUND

Despite calls for gender transformative family planning interventions to increase male engagement and female reproductive agency, there is limited research involving rigorous evaluation of the integration of these approaches. CHARM2 (counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) builds upon a prior three-session male engagement intervention by integrating female-focused sessions emphasizing women's choice and agency (i.e., gender synchronization). We hypothesized that CHARM2 participants will be more likely to report marital contraceptive use and communication and women's contraceptive agency, and less likely to report unintended pregnancy, relative to participants in the control condition.

METHODS

We conducted a two-armed cluster randomized controlled trial evaluating the effects of CHARM2 on marital contraceptive use, communication, decision-making; women's contraceptive agency, and pregnancy among young married couples in rural Maharashtra, India (ClinicalTrials.gov #NCT03514914, complete). 40 geographic clusters, defined based on the catchment areas of subcenter health facilities (the most proximal level of community health care within India's public health system) were randomized to control (n = 20) and intervention (n = 20). We assigned all participants within that geographic cluster to the corresponding cluster treatment condition; participants, investigators, and study staff were not masked to treatment assignment. Eligibility criteria included wife aged 18-29, couple residing together for at least six months with no plan for migration, and neither spouse sterilized or infertile. The CHARM2 intervention included five provider-delivered sessions on gender equity and family planning, two delivered in parallel to husbands and wives separately by gender-matched providers, and one final joint session, delivered within the four months subsequent to baseline survey. We conducted surveys and pregnancy testing at baseline and 9-month and 18-month follow-up. We used difference-in-differences multilevel mixed effects logistic regressions to assess CHARM2 effects on marital contraceptive use and communication, and women's contraceptive agency; we used single time point mixed effects logistic regressions for pregnancy outcomes. All analyses used an intention-to-treat approach.

FINDINGS

1201 couples were recruited between September 2018 and June 2019; 600 intervention and 601 control. All couples were included in outcome analyses. Full couple retention was 90·2% (n = 1083) at 9-month follow-up and 90·5% (n = 1087) at 18-month follow-up. Modern contraceptive use was higher among intervention participants at 9-month but not 18-month follow-up (9-month adjusted ratio of odds ratio [AROR] 1·5, 95% CI 1·03-2·3; 18-month AROR 0·8, 95% CI 0·4-1·4). Communication (9-month AROR 1·9, 95% CI 1·0-3·6; 18-month AROR 2·7, 95% CI 1·5-4·8) and agency (9-month AROR 5·1, 95% CI 1·2-22·4; 18-month AROR 8·1, 95% CI 1·4-48·2) both improved at both time points. There was no significant difference in pregnancy between groups over the 18-month period (AOR 0·8, 95% CI 0·7-1.1) However, for women who expressed fertility ambivalence at baseline, unintended pregnancy was marginally less likely among intervention participants (47% vs 19%) (p = 0·07). There were no reported adverse events.

INTERPRETATION

The CHARM2 intervention offers a scalable model to improve contraceptive use, communication, and agency and possibly decrease unplanned pregnancies for couples in rural India.

Sexual and reproductive health education and its association with ever use of contraception: a cross-sectional study among women in urban slums, Accra

Background

Sexual and reproductive health education among girls and women has several reproductive health benefits, including improved contraceptive knowledge, contraception use at first intercourse, increased chance of contraceptive use in a lifetime, and effective usage of contraceptives. It is however not clear whether women/girls in urban slums who have had sexual and reproductive health education would likely utilize contraception. This study sets out to test the hypothesis that Accra slum women who have had sex education have higher chances of ever using contraception.

Methods

A cross-sectional survey was conducted among reproductive aged women in two slums (i.e. Agbogbloshie and Old Fadama) in Accra, Ghana. A sample size of 691, made up of respondents who provided responses to the question on ever used contraception, sex education as well as those with complete information on all the other variables of interest was considered in this study. Binary logistic regression models were fitted to examine association between sexual and reproductive health education and ever use of contraception. Crude odds ratios (cOR) and adjusted odds ratios (aOR) at p-value less than 0.05 were used to assess the strength of the association between the outcome and independent variables.

Results

More than half (56.73%) of the women have never received sexual and reproductive health education. Most of the respondents (77.28%) had ever used contraceptives. Women who had no form of sexual and reproductive health education had lower odds of ever using contraception (OR = 0.641, 95% CI 0.443, 0.928) and this persisted after controlling for the effect of demographic factors (AOR = 0.652, 95% CI 0.436, 0.975] compared to those who have ever received any form of sex education. Non-married women as well as women who were exposed to media (newspapers/radio/television) were also more likely to use contraceptives in slums in Accra, Ghana.

Conclusion

The study revealed a relatively low prevalence of sex education among women in urban slums in Accra. However, sex education was found to increase the odds of ever use of contraception. These findings call for intensified sexual and reproductive health education among reproductive aged girls and women in urban slums in Accra using existing informal social networks and local media platforms.

Sexual and reproductive health education among girls and women has several reproductive health benefits, including improved contraceptive knowledge, contraception use at first intercourse, increased chance of contraceptive use in a lifetime, and effective usage of contraceptives. It is however not clear whether women/girls in urban slums who have had some form of sex education would likely utilize contraception more than those who have not. This study sets out to test the hypothesis that Accra slum women who have had sex education have higher chances of ever using contraception. A cross-sectional survey was conducted among reproductive aged women in two slums (i.e. Agbogbloshie and Old Fadama) in Accra, Ghana. A sample size of 691 girls/women aged 15–49 was considered. More than half (56.73%) of the women had never received some form of sex education. Most of the respondents (77.28%) had ever used contraceptives. Women who had no form of sex education had lower odds of ever using contraception and this persisted after controlling for the effect of demographic factors compared to those who have ever received any form of sex education. Non-married women as well as women who were exposed to media (newspapers/radio/television) were also more likely to use contraceptives in slums in Accra, Ghana. In sum, the study revealed that while prevalence of sex education was relatively low among urban slum women, sex education generally increased the chances of ever use of contraception. These findings call for more and targeted sexual and reproductive health education among reproductive aged girls and women in urban slums in Accra using existing informal social networks and local media platforms.