Demand satisfied by modern contraceptive among married women of reproductive age in Kenya

Background

Demand for family planning met/satisfied with modern contraceptive methods (mDFPS) has been proposed to track progress in Family Planning (FP) programs for Sustainable Development Goals. This study measured mDFPS among married women of reproductive age (MWRA) in Kenya to identify which groups were not being reached by FP programs.

Materials and methods

Performance, Monitoring and Accountability 2020 (PMA2020) survey data from 2014–2018 was used. PMA2020 surveys are cross-sectional including women 15–49 years. PMA2020 used a 2-stage cluster design with urban/rural regions as strata with random selection of households. Univariate and multivariate analysis was done using stata V15.

Results

Of the 34,832 respondents interviewed from 2014 to 2018, 60.2% were MWRA. There was a significant decrease in demand for FP from 2014 to 2018, p = 0.012. Lowest demand was among 15–19 and 45–49 years old women. Overall, modern contraceptive prevalence rate increased significantly from 54.6% to 60.8%, p = 0.004, being higher for women from urban areas, home visits by health care worker (HCW), educated, wealthy, visited health facilities and exposed to mass media. Unmet need for FP decreased from 23.0–13.8% over the 5-years, p<0.001. Married adolescent 15–19 had the highest unmet need and those from rural areas, poor, uneducated and not exposed to mass media. mDFPS increased significantly from 69.7–79.4% over the 5-years, p<0.001, with increase in long acting reversible contraception/permanent methods from 19.9–37.2% and decrease in short acting methods from 49.9–42.2%. Significant determinants of mDFPS were age, rural/urban residence, education, wealth, health facility visitation, exposure to FP messages via mass media in the last 12 months, year of study and county of residence.

Conclusions

Results show a good progress in key FP indicators. However, not all MWRA are being reached and should be reached if Kenya is to achieve the desired universal health coverage as well as Sustainable Development Goals. Targeted home visits by HCW as well increase in mass media coverage could be viable interventions.

Structural barriers to condom access in a community-based cohort of sex workers in Vancouver, Canada: influence of policing, violence and end-demand criminalisation

OBJECTIVES

Sex workers (SWs) face a disproportionate burden of HIV/sexually transmitted infections (STIs), violence and other human rights violations. While recent HIV prevention research has largely focused on the HIV cascade, condoms remain a cornerstone of HIV prevention, requiring further research attention. Given serious concerns regarding barriers to condom use, including policing, violence and 'end-demand' sex work criminalisation, we evaluated structural correlates of difficulty accessing condoms among SWs in Vancouver over an 8-year period.

METHODS

Baseline and prospective data were drawn from a community-based cohort of women SWs (2010-2018). SWs completed semi-annual questionnaires administered by a team that included lived experience (SWs). Multivariable logistic regression using generalised estimating equations (GEE) modelled correlates of difficulty accessing condoms over time.

RESULTS

Among 884 participants, 19.1% reported difficulty accessing condoms during the study. In multivariable GEE analysis, exposure to end-demand legislation was not associated with improved condom access; identifying as a sexual/gender minority (adjusted odds ratio (aOR) 1.62, 95% CI 1.16 to 2.27), servicing outdoors (aOR 1.52, 95% CI 1.17 to 1.97), physical/sexual workplace violence (aOR 1.98, 95% CI 1.44 to 2.72), community violence (aOR 1.79, 95% CI 1.27 to 2.52) and police harassment (aOR 1.66, 95% CI 1.24 to 2.24) were associated with enhanced difficulty accessing condoms.

CONCLUSIONS

One-fifth of SWs faced challenges accessing condoms, suggesting the need to scale-up SW-tailored HIV/STI prevention. Despite the purported goal of 'protecting communities', end-demand criminalisation did not mitigate barriers to condom access, while sexual/gender minorities and those facing workplace violence, harassment or those who worked outdoors experienced poorest condom accessibility. Decriminalisation of sex work is needed to support SWs' labour rights, including access to HIV/STI prevention supplies.

Primary and secondary three-month outcomes of a cluster-randomized trial of home-based postpartum contraceptive delivery in southwest Trifinio, Guatemala

DESIGN

This a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with implant utilization rates at 3 months post-enrollment.

METHODS

In a region of rural Guatemala referred to as the Southwest Trifinio, twelve communities are served by a community-based antenatal and postnatal care program. The communities were combined into eight clusters based on 2017 birth rates and randomized to receive the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit. All participants receive comprehensive contraceptive counseling beginning at the first antenatal visit, so control clusters received this as part of routine care; this education preceded the study intervention.

RESULTS

Once the 12 communities were combined into 8 clusters by expected birth volume and nurse team, which we expected to translate to eventual postpartum visits, the allocation sequence was generated in SAS. Of 208 women enrolled in the study, 108 were in four intervention and 100 in four control clusters. We used descriptive statistics to produce counts and percentages of characteristics of the study population overall and by intervention arm followed by univariate modeling using a mixed effects regression adjusted for cluster. Three-month contraceptive initiation rates were 56.0% in the control clusters compared to 76.8% in the intervention clusters, p < 0.001. Women in control clusters overwhelmingly opted for the injectable contraceptive (94.6%) while women in intervention clusters chose both the injection (61.5%) and the implant (33.7%), p < 0.001. Implant use by 3 months, the primary outcome of the study, was significantly higher in the intervention arm (25.9%) compared to the control arm (3.6%), p < 0.001, RR 1.3 CI [1.2, 1.4].

CONCLUSION

Our study was designed to respond to previously identified barriers to contraceptive uptake, and it was successful. Not only did it increase overall use of contraception by 3 months, but it shifted that contraceptive use away from short-acting methods in favor of longer-acting methods, with high continuation and satisfaction rates and no adverse outcomes reported.

TRIAL REGISTRATION

clinicaltrials.gov , NCT04005391 ; Retrospectively Registered 7/2/2019.

Facilitating community participation in family planning and contraceptive services provision and uptake: community and health provider perspectives

BACKGROUND

Although community participation has been identified as being important for improved and sustained health outcomes, designing and successfully implementing it in large scale public health programmes, including family planning and contraceptive (FP/C) service provision, remains challenging. Zambian participants in a multi-country project (the UPTAKE project) took part in the development of an intervention involving community and healthcare provider participation in FP/C services provision and uptake. This study reports key thematic areas identified by the study participants as critical to facilitating community participation in this intervention.

METHODS

This was an exploratory qualitative research study, conducted in Kabwe District, Central Province, in 2017. Twelve focus group discussions were conducted with community members (n = 114), two with healthcare providers (n = 19), and ten in-depth interviews with key community and health sector stakeholders. Data were analyzed using a thematic analysis approach.

RESULTS

Four thematic categories were identified by the participants as critical to facilitating community participation in FP/C services. Firstly, accountability in the recruitment of community participants and incorporation of community feedback in FP/C. programming. Secondly, engagement of existing community resources and structures in FP/C services provision. Thirdly, building trust in FP/C methods/services through credible community-based distributors and promotion of appropriate FP/C methods/services. Fourthly, promoting strategies that address structural failures, such as the feminisation of FP/C services and the lack FP/C services that are responsive to adolescent needs.

CONCLUSIONS

Understanding and considering community members' and healthcare providers' views regarding contextualized and locally relevant participatory approaches, facilitators and challenges to participation, could improve the design, implementation and success of participatory public health programmes, including FP/C.

Predictors of unmet need for contraception among adolescent girls and young women in selected high fertility countries in sub-Saharan Africa: A multilevel mixed effects analysis

INTRODUCTION

Despite the desire of adolescent girls and young women (AGYW) in sub-Saharan Africa (SSA) to use contraceptives, the majority of them have challenges with access to contraceptive services. This is more evident in high fertility countries in SSA. The purpose of this study was to examine the predictors of unmet need for contraception among AGYW in selected high fertility countries in SSA.

MATERIALS AND METHODS

Data from current Demographic and Health Surveys (DHS) carried out between 2010 and 2018 in 10 countries in SSA were analysed. A sample size of 24,898 AGYW who were either married or cohabiting was used. Unmet need for contraception was the outcome variable in this study. The explanatory variables were age, marital status, occupation, educational level, frequency of reading newspaper/magazine, frequency of listening to radio, frequency of watching television and parity (individual level variables) and wealth quintile, sex of household head, place of residence and decision-maker in healthcare (household/community level variables). Descriptive and multilevel logistic regression analyses were carried out. The results of the multilevel logistic regression analyses were reported using adjusted odds ratios at 95% confidence interval.

RESULTS

The prevalence of unmet need for contraception in all the countries considered in this study was 24.9%, with Angola, recording the highest prevalence of 42.6% while Niger had the lowest prevalence of 17.8%. In terms of the individual level predictors, the likelihood of unmet need for contraception was low among AGYW aged 20-24 [aOR = 0.82; 95% CI = 0.76-0.88], those with primary [aOR = 1.22; 95% CI = 1.13-1.31] and secondary/higher levels of formal education [aOR = 1.18; 95% CI = 1.08-1.28, p < 0.001], cohabiting AGYW [aOR = 1.52; 95% CI = 1.42-1.63] and AGYW with three or more births [aOR = 3.41; 95% CI = 3.02-3.85]. At the household/community level, the odds of unmet need for contraception was highest among poorer AGYW [aOR = 1.36; 95% CI = 1.21-1.53], AGYW in female-headed households [aOR = 1.22; 95% CI = 1.13-1.33], urban AGYW [aOR = 1.21; 95% CI = 1.11-1.32] and AGYW who took healthcare decisions alone [aOR = 1.10; 95% CI = 1.01-1.21].

CONCLUSION

This study has identified disparities in unmet need for contraception among AGYW in high fertility countries in SSA, with AGYW in Angola having the highest prevalence. Both individual and household/community level factors predicted unmet need for contraception among AGYW in this study. However, based on the ICC values, household/community level factors prevailed the individual level factors. Enhancing access to contraception among poorer AGYW, those in female-headed households, those in urban areas and those who take healthcare decisions alone by both governmental and non-governmental organisations in high fertility countries is recommended.

Evaluation of Senegal supply chain intervention on contraceptive stockouts using routine stock data

Background

Until 2011, stockouts of family planning commodities were common in Senegalese public health facilities. Recognizing the importance of addressing this problem, the Government of Senegal implemented the Informed Push Model (IPM) supply system, which involves logisticians to collect facility-level stock turnover data once a month and provide contraceptive supplies accordingly. The aims of this paper were to evaluate the impact of IPM on contraceptive availability and on stockout duration.

Methods and findings

To estimate the impact of the IPM on contraceptive availability, stock card data were obtained from health facilities selected through multistage sampling. A total number of 103 health facilities pertaining to 27 districts and nine regions across the country participated in this project. We compared the odds of contraceptive stockouts within the health facilities on the 23 months after the intervention with the 18 months before. The analysis was performed with a logistic model of the monthly time-series. The odds of stockout for any of the five contraceptive products decreased during the 23 months post-intervention compared to the 18 months pre-intervention (odds ratio, 95%CI: 0.34, 0.22–0.51).

To evaluate the impact of the IPM on duration of stockouts, a mixed negative binomial zero-truncated regression analysis was performed. The IPM was not effective in reducing the duration of contraceptive stockouts (incidence rate ratio, 95%CI: 0.81, 0.24–2.7), except for the two long-acting contraceptives (intrauterine devices and implants). Our model predicted a decrease in stockout median duration from 23 pre- to 4 days post-intervention for intrauterine devices; and from 19 to 14 days for implants.

Conclusions

We conclude that the IPM has resulted in greater efficiency in contraceptive stock management, increasing the availability of contraceptive methods in health facilities in Senegal. The IPM also resulted in decreased duration of stockouts for intrauterine devices and implants, but not for any of the short-acting contraception (pills and injectables).

Improving access to and use of contraception by adolescents: What progress has been made, what lessons have been learnt, and what are the implications for action?

This article sets out the progress that has been made in reducing levels of adolescent childbearing and in meeting adolescent contraceptive needs, over the last 25 years, and also makes the public health, economic, and human rights rationale for continued attention to and investment in these areas. Using an analytic framework that covers the perspectives of both the use and the provision of contraception, it examines the factors that make it difficult for adolescents to obtain and use contraceptives to avoid unintended pregnancies, and outlines what could be done to address these factors, drawing from research evidence and programmatic experience. In doing this, the article provides concrete examples from low- and middle-countries that have made tangible progress in these areas.

Barriers to contraceptive careseeking: the experience of Eritrean asylum-seeking women in Israel

Objectives: In recent years, there has been a mass migration of Eritreans (many seeking political asylum) into Israel after precarious irregular movement across international borders. This study qualitatively explores the structural barriers to family planning (i.e. contraceptive services) for Eritrean women in Israel that are rooted in their temporary legal status and the patchwork of family planning services.Design/Methods: From December 2012 to September 2013, we interviewed 25 key informants (NGO workers, researchers, Eritrean community activists, International NGO representatives and Ministry of Health officials) and 12 Eritrean asylum seekers. We also conducted 8 focus groups with Eritrean asylum seekers. Data were analyzed using both inductive and deductive coding.Results: We identified 7 main barriers to accessing family planning services: (1) distance to health facilities; (2) limited healthcare resources; (3) fragmentation of the healthcare system; (4) cost of contraceptive services; (5) low standard of care in private clinics; (6) discrimination; and (7) language barriers.Conclusion: The political, economic and social marginalization of Eritrean asylum-seeking women in Israel creates structural barriers to family planning services. Their marginalization complicates providers' efforts (NGO and governmental) to provide them with comprehensive healthcare, and hinders their ability to control their sexual and reproductive health. Failure to act on this evidence may perpetuate the pattern of unwanted pregnancies and social and economic disparities in this population.

Unmet need for modern contraception and associated factors among reproductive age group women in Eritrean refugee camps, Tigray, north Ethiopia: a cross-sectional study

OBJECTIVE

Millions of women want to delay or avoid pregnancy, but they are not using contraception, especially in refugee settings. Due to lack of contraception, one fifth of reproductive age group women suffered from unwanted pregnancy and unsafe abortion, which accounted for 78% of maternal mortality in refugee camps. Therefore, the aim of this study was to assess the prevalence of unmet need for modern contraception and its associated factors among reproductive age group women in Eritrean refugee camps, Tigray, Northern Ethiopia, 2016.

RESULTS

400 women of reproductive age group interviewed. Prevalence of unmet need for modern contraception in this study was found to be 41.8% (95% CI 36.99%, 46.63%).Respondents' unfavorable attitude towards modern contraceptive methods [AOR = 0.372, 95% CI 0.170, 0.818] and the availability of modern contraceptive methods [AOR = 3.501, 95% CI 1.328, 9.231] were factors significantly associated with unmet need for modern contraception. Respondents' attitude towards modern contraceptive methods and availability of modern contraceptives were independent predictors of unmet need. Governmental and non-governmental organizations should design programs to create behavioral change in women's attitude towards contraceptive use and to secure the availability of contraceptive methods in refugee camp settings.

Community and health systems barriers and enablers to family planning and contraceptive services provision and use in Kabwe District, Zambia

BACKGROUND

Unmet need for contraception results in several health challenges such as unintended pregnancies, unwanted births and unsafe abortions. Most interventions have been unable to successfully address this unmet need due to various community and health system level factors. Identifying these inhibiting and enabling factors prior to implementation of interventions forms the basis for planning efforts to increase met needs. This qualitative study was part of the formative phase of a larger research project that aimed to develop an intervention to increase met needs for contraception through community and health system participation. The specific study component reported here explores barriers and enablers to family planning and contraceptive services provision and utilisation at community and health systems levels.

METHODS

Twelve focus group discussions were conducted with community members (n = 114) and two with healthcare providers (n = 19). Ten in-depth interviews were held with key stakeholders. The study was conducted in Kabwe district, Zambia. Interviews/discussions were translated and transcribed verbatim. Data were coded and organised using NVivo 10 (QSR international), and were analysed using thematic analysis.

RESULTS

Health systems barriers include long distances to healthcare facilities, stock-outs of preferred methods, lack of policies facilitating contraceptive provision in schools, and undesirable provider attitudes. Community level barriers comprise women's experience with contraceptive side effects, myths, rumours and misconceptions, societal stigma, and negative traditional and religious beliefs. On the other hand, health systems enablers consist of political will from government to expand contraceptive services access, integration of contraceptive services, provision of couples counselling, and availability of personnel to offer basic methods mix. Functional community health system structures, community desire to delay pregnancy, and knowledge of contraceptive services are enablers at a community level.

CONCLUSIONS

These study findings highlight key community and health systems factors that should be considered by policy, program planners and implementers in the design and implementation of family planning and contraceptive services programmes, to ensure sustained uptake and increased met needs for contraceptive methods and services.

The state of sexual health services at U.S. Colleges and Universities

OBJECTIVE

To describe the array of sexual health care services provided at US colleges and universities.

PARTICIPANTS

During 2014-2015, 885 colleges were surveyed about their provision of sexual health services.

METHODS

55% of colleges responded. Data were weighted and stratified by minority-serving institutions (MSIs), 2-year and 4-year institutions.

RESULTS

70.6% of colleges reported having a health center (HC), of which 73.0% offered STI diagnosis/treatment (4 years vs. 2 years; 77.9% vs. 53.1%) and contraceptive services (70.1% vs. 46.4%), all p < .001. HCs less frequently offered LARC (19.7%), express STI testing (24.4%) and self-collection (31.4%). Condoms were available on 66.8% of campuses. HPV vaccination was available at more 4-year colleges (73.7% vs. 48.5%, p < .003) and non-MSIs (74.4% vs. 58.5, p = .019). Regarding MSM-targeted services, 54.6% offered pharyngeal and 51.8% rectal STI testing.

CONCLUSIONS

2-year colleges may require additional support with providing sexual health care. Improvements could entail increasing express testing, extra-genital STI testing, and LARC.

Getting to FP2020: Harnessing the private sector to increase modern contraceptive access and choice in Ethiopia, Nigeria, and DRC

Background

An estimated 214 million women have unmet need for family planning in developing regions. Improved utilization of the private sector is key to achieving universal access to a range of safe and effective modern contraceptive methods stipulated by FP2020 and SDG commitments. Until now, a lack of market data has limited understanding of the private sector’s role in increasing contraceptive coverage and choice.

Methods

In 2015, the FPwatch Project conducted representative outlet surveys in Ethiopia, Nigeria, and DRC using a full census approach in selected administrative areas. Every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, availability, and price.

Findings

Excluding general retailers, 96% of potential outlets in Ethiopia, 55% in Nigeria, and 41% in DRC had modern contraceptive methods available. In Ethiopia, 41% of modern contraceptive stocking outlets were in the private sector compared with approximately 80% in Nigeria and DRC where drug shops were dominant. Ninety-five percent of private sector outlets in Ethiopia had modern contraceptive methods available; 37% had three or more methods. In Nigeria and DRC, only 54% and 42% of private sector outlets stocked modern contraceptives with 5% and 4% stocking three or more methods, respectively. High prices in Nigeria and DRC create barriers to consumer access and choice.

Discussion

There is a missed opportunity to provide modern contraception through the private sector, particularly drug shops. Subsidies and interventions, like social marketing and social franchising, could leverage the private sector’s role in increasing access to a range of contraceptives. Achieving global FP2020 commitments depends on the expansion of national contraceptive policies that promote greater partnership and cooperation with the private sector and improvement of decisions around funding streams of countries with large populations and high unmet need like Ethiopia, Nigeria, and DRC.

The Zika Contraception Access Network: a feasibility programme to increase access to contraception in Puerto Rico during the 2016-17 Zika virus outbreak

BACKGROUND

Prevention of unintended pregnancy is a primary strategy to reduce adverse pregnancy and birth outcomes related to Zika virus infection. The Zika Contraception Access Network (Z-CAN) aimed to build a network of health-care providers offering client-centred contraceptive counselling and the full range of reversible contraception at no cost to women in Puerto Rico who chose to prevent pregnancy during the 2016-17 Zika virus outbreak. Here, we describe the Z-CAN programme design, implementation activities, and baseline characteristics of the first 21 124 participants.

METHODS

Z-CAN was developed by establishing partnerships between federal agencies, territorial health agencies, private corporations, and domestic philanthropic and non-profit organisations in the continental USA and Puerto Rico. Private donations to the National Foundation for the Centers for Disease Control and Prevention (CDCF) secured a supply of reversible contraceptive methods (including long-acting reversible contraception), made available to non-sterilised women of reproductive age at no cost through provider reimbursements and infrastructure supported by the CDCF. To build capacity in contraception service provision, doctors and clinic staff from all public health regions and nearly all municipalities in Puerto Rico were recruited into the programme. All providers completed 1 day of comprehensive training in contraception knowledge, counselling, and initiation and management, including the insertion and removal of long-acting reversible contraceptives (LARCs). Z-CAN was announced through health-care providers, word of mouth, and a health education campaign. Descriptive characteristics of programme providers and participants were recorded, and we estimated the factors associated with choosing and receiving a LARC method. As part of a Z-CAN programme monitoring plan, participants were invited to complete a patient satisfaction survey about whether they had obtained free, same-day access to their chosen contraceptive method after receiving comprehensive counselling, their perception of the quality of care they had received, and their satisfaction with their chosen method and services.

FINDINGS

Between May 4, 2016, and Aug 15, 2017, 153 providers in the Z-CAN programme provided services to 21 124 women. 20 110 (95%) women received same-day provision of a reversible contraceptive method. Whereas only 767 (4%) women had used a LARC method before Z-CAN, 14 259 (68%) chose and received a LARC method at their initial visit. Of the women who received a LARC method, 10 808 (76%) women had used no method or a least effective method of contraception (ie, condoms or withdrawal) before their Z-CAN visit. Of the 3489 women who participated in a patient satisfaction survey, 3068 (93%) of 3294 women were very satisfied with the services received, and 3216 (93%) of 3478 women reported receiving the method that they were most interested in after receiving counselling. 2382 (78%) of 3040 women rated their care as excellent or very good.

INTERPRETATION

Z-CAN was designed as a short-term response for rapid implementation of reversible contraceptive services in a complex emergency setting in Puerto Rico and has served more than 21 000 women. This model could be replicated or adapted as part of future emergency preparedness and response efforts.

FUNDING

National Foundation for the Centers for Disease Control and Prevention.

General practice consultations and use of prescription drugs after changes to school absence policy

BACKGROUND

New rules for absence with stricter requirements for documentation were introduced in upper secondary schools in the autumn of 2016. We investigated the use of general practice services and dispensing of prescription drugs among 16 – 18-year-olds in the autumn of 2016 and compared this with equivalent figures for the period 2013 – 15.

MATERIAL AND METHOD

We retrieved information on consultations in general practice (GP) and dispensing of prescription drugs to 15 – 18-year-olds in the period 2013 – 16 from the Directorate of Health’s system for control and payment of health reimbursements (KUHR) and the Norwegian Prescription Database respectively. The number of consultations and dispensing of drugs were compared to previous years using Poisson regression (reference year 2015). The incidence rate ratio (IRR) was used as an outcome measure.

RESULTS

The number of GP consultations for 16 – 18-year-olds was 30 % higher in the autumn of 2016 than in the autumn of 2015 (IRR 1.30, 95 % confidence interval (CI) 1.29 – 1.31). In the same period, the dispensing of drugs to this age group increased by 8 % (IRR 1.08, 95 % CI 1.08 – 1.09). Among the diagnosis groups, respiratory tract infections had the largest increase (IRR 2.21, 95 % CI 2.17 – 2.25). The largest increase in drug dispensing was found for remedies for coughs and colds (IRR 1.73, 95 % CI 1.65 – 1.80).

INTERPRETATION

The increase in consultations in general practice and dispensing of drugs to 16 – 18-year-olds coincided in time with the introduction of new rules for absence from school. We hold it to be highly likely that the changes were caused by the stricter rules for documentation of absence from school.

Meeting the Contraceptive Needs of a Community: Increasing Access to Long-Acting Reversible Contraception

To control their reproductive lives, women must have access to all contraceptive methods including the most effective reversible methods, intrauterine devices, and implants. The Contraceptive CHOICE Project, a study of 9,256 women in St. Louis, showed that when barriers to contraception are removed, many women choose intrauterine devices and implants, substantially reducing rates of unintended pregnancy and abortion. This article discusses strategies we learned from the CHOICE Project to improve uptake of the most effective contraceptive methods.

Barriers to Modern Contraceptive Use in Kinshasa, DRC

Recent research from Kinshasa, DRC, has shown that only one in five married women uses modern contraception; over one quarter have an unmet need for family planning; and almost 400 health facilities across Kinshasa report that they provide modern contraception. This study addresses the question: with reasonable physical access and relatively high unmet need, why is modern contraceptive prevalence so low? To this end, the research team conducted 6 focus groups of women (non-users of any method, users of traditional methods, and users of modern methods) and 4 of husbands (of users of traditional methods and in non-user unions) in health zones with relatively strong physical access to FP services. Five key barriers emerged from the focus group discussions: fear of side effects (especially sterility), costs of the method, sociocultural norms (especially the dominant position of the male in family decision-making), pressure from family members to avoid modern contraception, and lack of information/misinformation. These findings are very similar to those from 12 other studies of sociocultural barriers to family planning in sub-Saharan Africa. Moreover, they have strong programmatic implications for the training of FP workers to counsel future clients and for the content of behavior change communication interventions.

Access to Emergency Contraception and its Impact on Fertility and Sexual Behavior

Half of all pregnancies in the USA are unintended, suggesting a high incidence of either improper or nonuse of contraceptives. Emergency birth control (EBC) provides individuals with additional insurance against unplanned pregnancy in the presence of contraception failure. This study is the first to estimate the impact of switching EBC from prescription to nonprescription status in the USA on abortions and risky sexual behavior as measured by STD rates. Utilizing state-level variation in access to EBC, we find that providing individuals with over-the-counter access to EBC leads to increase STD rates and has no effect on abortion rates. Moreover, individual-level analysis using the National Longitudinal Survey of Youth indicates that risky sexual behavior such as engaging in unprotected sex and number of sexual encounters increases as a result of over-the-counter access to EBC, which is consistent with the state-level STD findings.

Sustainable Cost Models for mHealth at Scale: Modeling Program Data from m4RH Tanzania

Background

There is increasing evidence that mobile phone health interventions (“mHealth”) can improve health behaviors and outcomes and are critically important in low-resource, low-access settings. However, the majority of mHealth programs in developing countries fail to reach scale. One reason may be the challenge of developing financially sustainable programs. The goal of this paper is to explore strategies for mHealth program sustainability and develop cost-recovery models for program implementers using 2014 operational program data from Mobile for Reproductive Health (m4RH), a national text-message (SMS) based health communication service in Tanzania.

Methods

We delineated 2014 m4RH program costs and considered three strategies for cost-recovery for the m4RH program: user pay-for-service, SMS cost reduction, and strategic partnerships. These inputs were used to develop four different cost-recovery scenarios. The four scenarios leveraged strategic partnerships to reduce per-SMS program costs and create per-SMS program revenue and varied the structure for user financial contribution. Finally, we conducted break-even and uncertainty analyses to evaluate the costs and revenues of these models at the 2014 user volume (125,320) and at any possible break-even volume.

Results

In three of four scenarios, costs exceeded revenue by $94,596, $34,443, and $84,571 at the 2014 user volume. However, these costs represented large reductions (54%, 83%, and 58%, respectively) from the 2014 program cost of $203,475. Scenario four, in which the lowest per-SMS rate ($0.01 per SMS) was negotiated and users paid for all m4RH SMS sent or received, achieved a $5,660 profit at the 2014 user volume. A Monte Carlo uncertainty analysis demonstrated that break-even points were driven by user volume rather than variations in program costs.

Conclusions

These results reveal that breaking even was only probable when all SMS costs were transferred to users and the lowest per-SMS cost was negotiated with telecom partners. While this strategy was sustainable for the implementer, a central concern is that health information may not reach those who are too poor to pay, limiting the program’s reach and impact. Incorporating strategies presented here may make mHealth programs more appealing to funders and investors but need further consideration to balance sustainability, scale, and impact.

Improving contraceptive choice: fidelity of implementation and the gap between effectiveness and efficacy

Interventions to reduce unintended pregnancy through improved contraceptive use are a public health priority. A comprehensive process evaluation of a contraceptive assessment module intervention with demonstrated efficacy was undertaken. The 12-month process evaluation goal was to describe the extent to which the intervention was implemented as intended over time, and to identify programmatic adjustments to improve implementation fidelity. Quantitative and qualitative methods included staff surveys, electronic health record data, usage monitoring, and observations. Fidelity of implementation was low overall (<10% of eligible patients completed the entire module [dose received]). Although a midcourse correction making the module available in clinical areas led to increased dose delivered (23% vs. 30%, chi-square test p = .006), dose received did not increase significantly after this adjustment. Contextual factors including competing organizational and staff priorities and staff buy-in limited the level of implementation and precluded adoption of some strategies such as adjusting patient flow. Using a process evaluation framework enabled the research team to identify and address complexities inherent in effectiveness studies and facilitated the alignment of program and context.

Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage

OBJECTIVE

The purpose of this study was to determine the use of contraceptive methods, which was defined by effectiveness, length of coverage, and their association with short interpregnancy intervals, when controlling for provider type and client demographics.

STUDY DESIGN

We identified a cohort of 117,644 women from the 2008 California Birth Statistical Master file with second or higher order birth and at least 1 Medicaid (Family Planning, Access, Care, and Treatment [Family PACT] program or Medi-Cal) claim within 18 months after index birth. We explored the effect of contraceptive method provision on the odds of having an optimal interpregnancy interval and controlled for covariates.

RESULTS

The average length of contraceptive coverage was 3.81 months (SD = 4.84). Most women received user-dependent hormonal contraceptives as their most effective contraceptive method (55%; n = 65,103 women) and one-third (33%; n = 39,090 women) had no contraceptive claim. Women who used long-acting reversible contraceptive methods had 3.89 times the odds and women who used user-dependent hormonal methods had 1.89 times the odds of achieving an optimal birth interval compared with women who used barrier methods only; women with no method had 0.66 times the odds. When user-dependent methods are considered, the odds of having an optimal birth interval increased for each additional month of contraceptive coverage by 8% (odds ratio, 1.08; 95% confidence interval, 1.08-1.09). Women who were seen by Family PACT or by both Family PACT and Medi-Cal providers had significantly higher odds of optimal birth intervals compared with women who were served by Medi-Cal only.

CONCLUSION

To achieve optimal birth spacing and ultimately to improve birth outcomes, attention should be given to contraceptive counseling and access to contraceptive methods in the postpartum period.

Of paradox and plausibility: the dynamic of change in medical law

This article develops a model of change in medical law. Drawing on systems theory, it argues that medical law participates in a dynamic of 'deparadoxification' and 'reparadoxification' whereby the underlying contingency of the law is variously concealed through plausible argumentation, or revealed by critical challenge. Medical law is, thus, thoroughly rhetorical. An examination of the development of the law on abortion and on the sterilization of incompetent adults shows that plausibility is achieved through the deployment of substantive common sense and formal stylistic devices. It is undermined where these elements are shown to be arbitrary and constructed. In conclusion, it is argued that the politics of medical law are constituted by this antagonistic process of establishing and challenging provisionally stable normative regimes.

'Clueless about contraception': the introduction and circulation of the contraceptive pill in state-socialist Poland (1960s-1970s)

This paper discusses the introduction of the pill into the state-socialist Polish market in the late 1960s and its circulation over the following decade. Abortion, legalised for socio-economic reasons in 1956, had been available practically on demand since 1959, and there were no legal obstacles to contraception. The pill first appeared in Poland in the early 1960s, but was not widely available in pharmacies until 1969, when the local pharmaceutical industry began production. Throughout the 1970s, only two brands were widely available: Femigen and Angravid. The pill played a marginal role in family planning during the 1960s and 1970s in Poland, with cycle-observation, backed by the possibility of a legal abortion, being the main resource for birth control. This was due to structural limits to the distribution of the pill on a centrally-planned market closed to Western pharmaceutical companies, cultural patterns of sexual behaviour, and the availability of abortion.

Use of human rights to meet the unmet need for family planning

In this report, we describe how human rights can help to shape laws, policies, programmes, and projects in relation to contraceptive information and services. Applying a human rights perspective and recognising the International Conference on Population and Development and Millennium Development Goal commitments to universal access to reproductive health including family planning, we support measurement of unmet need for family planning that encompasses more groups than has been the case until recently. We outline how human rights can be used to identify, reduce, and eliminate barriers to accessing contraception; the ways in which human rights can enhance laws and policies; and governments' legal obligations in relation to contraceptive information and services. We underline the crucial importance of accountability of states and identify some of the priorities for making family planning available that are mandated by human rights.

Achievements of the Iranian family planning programmes 1956-2006

Family planning programmes initiated in the Islamic Republic of Iran from 1966 met with limited success. Following the 1986 census family planning was considered a priority and was supported by the country's leaders. Appropriate strategies based on the principles of health promotion led to an increase in the contraceptive prevalence rate among married women from 49.0% in 1989 to 73.8% in 2006. This paper reviews the family planning programmes in the Islamic Republic of Iran and their achievements during the last 4 decades and discusses the principles of health promotion and theories of behaviour change which may explain these achievements. Successful strategies included: creation of a supportive environment, reorientation of family planning services, expanding of coverage of family planning services, training skilled personnel, providing free contraceptives as well as vasectomy and tubectomy services, involvement of volunteers and nongovernmental organizations and promotion of male participation.

Demand for long acting and permanent contraceptive methods and associated factors among family planning service users, Batu town, Central Ethiopia

BACKGROUND

Evidence suggests a high unsatisfied demand for long acting and permanent contraceptive methods in sub-Saharan Africa. However, there is limited knowledge on demand for long acting and permanent contraceptive methods and associated factors in Ethiopia.

OBJECTIVE

The objective of this study was to assess demand for long acting and permanent contraceptive methods and associated factors among women of age group 18-49 years in Batu town, East Shoa Zone, Ethiopia.

METHODOLOGY

A facility based cross-sectional survey was conducted in six service delivery points from March to April 2009 on 398 women of age 18-49 years old.

RESULTS

Thirteen (3%) were using long acting and permanent contraceptive methods and 89 (22.4%) wanted no more child in the future making the total demand of long acting and permanent contraceptive methods 24.4%. Older age group, multiparty, that the provider asked about reproductive intention, and the provider explained side effects of method selected were significantly associated with using LA and MPs (P < 0.05).

CONCLUSION

There is high total demand and several socio demographic and family planning service quality related factors were associated with demand for long acting and permanent contraceptive methods indicating that multi-dimensional measures are needed to improve the use of long acting and permanent contraceptive methods.

Prevalence of unmet contraceptive need among Egyptian women: a community-based study

INTRODUCTION

An estimated 17% of married women in the developing world still have an unmet need for contraception. This study aimed to measure the prevalence and reasons for unmet contraceptive need among married women in the childbearing period in an underprivileged district in Eastern Cairo.

METHODS

A cluster survey of 2340 women in the Marg district of Eastern Cairo was performed. Socio-demographic data and data on both past and present contraceptive use were obtained by interview questionnaire.

RESULTS

The prevalence of unmet need was 7.4%; 53.4% for limiting and 46.6% for spacing. Experience of side effects from contraceptive use, and fear of side effects, was highly prevalent among women with unmet need. In addition, a large proportion of women with unmet need perceived themselves not to be at risk for conceiving.

CONCLUSIONS

A substantial proportion of women in Cairo have unmet contraceptive need. Efficient counseling of women about contraception may help reduce this high prevalence.

Supply and demand challenges to modern contraceptive use in Azerbaijan

OBJECTIVES

We conducted a survey of health facilities and household members to determine supply and demand aspects of contraceptive use in Azerbaijan.

METHODS

In June 2005, we conducted interviews with 758 women and 253 men in a community-based survey in 40 communities in five districts. We also surveyed a sample of health facilities and pharmacies and conducted interviews with key informants.

RESULTS

Both men and women in these communities desire small families, yet significant supply and demand impediments exist. Despite community interest, lack of knowledge of contraception is prevalent. Fear of side effects plays a role in non-use and discontinuation of modern methods, although little opportunity exists for counselling on side effects, since few health workers are trained. An obstacle to use is legislation that only allows contraception to be prescribed by gynaecologists, who are mostly concentrated in the hospitals of urban centres. However, the main handicap to increased use of modern contraception, is insufficient contraceptive supply. Not only is there a lack of method choice nationally, but few of the facilities we surveyed had any contraceptives available. This situation threatens to worsen as the United Nations Population Fund (UNFPA) retracts commodities' funding.

CONCLUSIONS

The lack of knowledge of modern contraception, lack of trained staff and poor commodity availability signals that much remains to be done for the people of Azerbaijan to achieve their fertility control goals.

Access to contraceptive services among unmarried young people in the north-east of China

OBJECTIVE

The concerns about the potential threats of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have increased, since, in China, there is a lack of sexual education and condom use is rare. A community-based survey was conducted in September 2001 in Changchun city among 1227 unmarried young people aged 15-24 years (619 males and 608 females) to assess risky sexual practices and the obstacles to accessing appropriate contraceptive and other services.

METHOD

The study comprised a survey employing self-administered questionnaires, as well as key informant interviews, focus group discussions and in-depth interviews. This paper investigates the factors associated with young people's access to contraceptive services.

RESULTS

Results showed that 16% of young people had experienced premarital sexual intercourse and, among them, only 48.2% used contraceptive methods during the first sexual intercourse; 29.9% used a condom. Drug stores were the main source of contraceptives.

CONCLUSIONS

While data are sparse, findings suggest that the hostile and judgmental attitudes of providers, as well as the lack of counseling and privacy, were the key obstacles that unmarried youth encountered in their search for contraceptive services. Findings suggest the need for a reorientation of the contraceptive services to focus on unmarried youth, and generally to make contraceptive services more accessible to young people.

An assessment of postabortion care in three regions in Ethiopia, 2000 to 2004

OBJECTIVE

To assess postabortion care services in 3 regions in Ethiopia following provider training and service improvements between 2000 and 2004.

METHODS

Data on availability and quality of services were collected at 119 facilities in 3 regions of Ethiopia before and after postabortion care (PAC) provider training in 42 of the sites; supervision, supplies, and equipment were also provided. Changes over time, changes attributable to the training intervention, and overall self-reported improvements in PAC were assessed for outcomes of interest, including availability of uterine evacuation services, postabortion contraceptive methods and supply availability (including manual vacuum aspiration [MVA]), and minimum-skilled providers.

RESULTS

Between 2000 and 2004, the capacity for offering uterine evacuation increased from 57% to 79% among intervention facilities, while remaining relatively constant among the comparison facilities. The training intervention was significantly associated with improvements in the availability and use of MVA, the availability of a minimum number of skilled providers and availability of postabortion contraceptive services. The proportion of uterine evacuation procedures performed with MVA increased among comparison facilities, but increased even more among intervention facilities, from 14% to 50% of procedures.

CONCLUSIONS

Training and supporting providers in comprehensive PAC effectively improve women's access to PAC services in Ethiopia, but more attention must be paid to training midlevel providers, extending services into health centers, pain management, and provision of postabortion contraceptives.

Factors in consistency between attitudes and behavior: implications for policies and programs. 1981-82

The paper deals with the factors which affect contraceptive attitudes, behaviors, and the relationship between the two. The analysis is based upon original survey data from 2,446 women in Venezuela and related literature. The results suggest that both positive attitudes and contraceptive accessibility are major determinants of contraception but at the aggregate level neither has a decisive advantage over the other. The three best predictors of contraceptive use are: specific contraceptive attitudes, social support, and accessibility of contraceptives. Their impacts on behavior are direct and additive; however, their impacts vary significantly by education and number of living children. In general attitude change strategy is more effective with younger women while improving accessibility affects older women more often. Implications for policy and programs are presented.

Four criteria to evaluate providers' service-delivery response to new contraceptive introduction

This article presents an evaluation framework developed to assess the first-level effects of introducing the Standard Days Method (SDM) in Peru Ministry of Health clinics. Four questions are asked: 1) To what extent do providers routinely achieve SDM service delivery standards? 2) Is the time invested in SDM delivery consistent with program norms? 3) How does SDM delivery compare with delivery of established methods? and 4) How does SDM introduction affect delivery of established methods? A study at 62 clinics demonstrated the framework's usefulness. The Standard Days Method introduction had positive overall effects on the quality of care but provider training needed adjustments.

Contraception today

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution-the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and-thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control. At the turn of the millennium, all over the world, more than 600 million married women are using contraception, with nearly 500 million in developing countries. Among married women, contraceptive use rose in all but two developing countries surveyed more than once since 1990. Among unmarried, sexually active women, it grew in 21 of 25 countries recently surveyed. Hormonal contraception, the best known method, first made available as a daily pill, can today be administered through seven different routes: intramuscularly, intranasally, intrauterus, intravaginally, orally, subcutaneously, and transdermally. In the field of oral contraception, new strategies include further dose reduction, the synthesis of new active molecules, and new administration schedules. A new minipill (progestin-only preparation) containing desogestrel has been recently marketed in a number of countries and is capable of consistently inhibiting ovulation in most women. New contraceptive rings to be inserted in the vagina offer a novel approach by providing a sustained release of steroids and low failure rates. The transdermal route for delivering contraceptive steroids is now established via a contraceptive patch, a spray, or a gel. The intramuscular route has also seen new products with the marketing of improved monthly injectable preparations containing an estrogen and a progestin. After the first device capable of delivering progesterone directly into the uterus was withdrawn, a new system releasing locally 20 microg evonorgestrel is today marketed in a majority of countries with excellent contraceptive and therapeutic performance. Finally, several subcutaneously implanted systems have been developed: contraceptive "rods," where the polymeric matrix is mixed with the steroid and "capsules" made of a hollow polymer tube filled with free steroid crystals. New advances have also been made in nonhormonal intrauterine contraception with the development of "frameless" devices. The HIV/AIDS pandemic forced policy makers to look for ways to protect young people from sexually transmitted diseases as well as from untimely pregnancies. This led to the development of the so-called dual protection method, involving the use of a physical barrier (condom) as well as that of a second, highly effective contraceptive method. More complex is the situation with antifertility vaccines, still at a preliminary stage of development and unlikely to be in widespread use for years to come. Last, but not least, work is in progress to provide effective emergency contraception after an unprotected intercourse. Very promising in this area is the use of selective progesterone receptor modulators (antiprogestins).

Unwanted fertility among the poor: an inequity?

OBJECTIVE

To determine if higher fertility and lower contraceptive use among the poorer segments of society should be considered an inequality, reflecting a higher desire for large families among the poor, or an inequity, a product of the poor being prevented from achieving their desired fertility to the same degree as wealthier segments of society.

METHODS

Using the most recent Demographic and Health Surveys from 41 countries, we analysed the differences in fertility in light of modern contraceptive use, unwanted fertility (defined as actual fertility in excess of desired fertility) and the availability of family planning services found among poorer and wealthier segments of society. The asset index in each survey was used to construct wealth quintiles and the concentration index (CI) of income inequality was found in health variables.

FINDINGS

The relationship between the CI found in the total fertility rate and the use of contraceptives was linear, R-square of 0.289. Unwanted births in the poorest quintile were more than twice that found in the wealthiest quintile, respectively 1.2 and 0.5, although there was wide variation among the 41 countries. The CI in our measure of family planning availability (radio messages, knowledge of services and contact with field workers) was largely positively associated with the CI in modern contraceptive prevalence, respectively R-squares of 0.392, 0.692 and 0.526.

CONCLUSION

In many countries the higher fertility and lower contraceptive use found among poorer relative to wealthier populations should be considered an inequity.

Inconsistencies in the Relationship Between Contraceptive Use and Fertility in Bangladesh

CONTEXT

Contraceptive prevalence increased by nine percentage points from 1993 to 2000 in Bangladesh, but there was almost no decline in the total fertility rate.

METHODS

Data from the 1999-2000 Bangladesh Demographic and Health Survey and from the Matlab Demographic Surveillance System area collected between 1978 and 2001 were analyzed to explain the lack of change in fertility and to examine relationships among contraceptive prevalence, the abortion ratio, desired fertility and total fertility.

RESULTS

After a maternal and child health and family planning program was initiated in part of Matlab in 1977, the total fertility rate in the intervention area declined from 4.8 in 1979 to 2.9 in 2000, while fertility in the comparison area dropped from 6.3 to 3.5. Over this period, contraceptive prevalence rose from 30% to 70% and from 16% to 50% in the two areas, respectively; meanwhile, the abortion ratio fell from 4.3 to 3.6 in the intervention area, but rose from around two to 8.2 in the comparison area. Trends in desired fertility in each area were similar, declining from about 4.0 children per woman in 1979 to about 2.5 children in 2000. Among women at each level of parity, fertility generally decreased as the number of sons increased, and fertility was highest for women without sons.

CONCLUSIONS

Preference for male children and parental concern over infant and child mortality may partially explain the difference between desired family size and fertility. A reduction in breast-feeding and an increase in use of less-effective contraceptive methods might be responsible for the inconsistency in the relationship between contraceptive use and fertility.

Atenção ao planejamento familiar no Brasil hoje: reflexões sobre os resultados de uma pesquisa

Realizou-se estudo com uma primeira etapa descritiva, de corte transversal, e segunda etapa qualitativa, de estudo de casos. Avaliou-se a disponibilidade de métodos anticoncepcionais nas Unidades Básicas de saúde de municípios brasileiros, e características da atenção ao planejamento familiar e a articulação com a estratégia de saúde da família. Inicialmente, foram aplicados, por telefone, questionários sobre o recebimento recente de métodos anticoncepcionais, em municípios selecionados a partir de um plano complexo de amostragem. Na etapa qualitativa foram selecionados propositalmente e visitados quatro municípios, onde se realizaram observação e entrevistas semi-estruturadas com gestores e profissionais de saúde. Procedeu-se a análise estatística descritiva e regressão logística múltipla dos dados quantitativos. Para os qualitativos adotou-se a técnica de análise temática do conteúdo. Verificou-se que as ações de planejamento familiar, com freqüência, são executadas de forma isolada e que os profissionais das equipes de saúde da família não entendiam o planejamento familiar como parte da atenção básica e não se consideravam capacitados para prestar assistência nessa área. A atenção ao planejamento familiar continua a ser marcada pela indisponibilidade de métodos anticoncepcionais nos serviços públicos de saúde.

The potential impact of community-based distribution programmes on contraceptive uptake in resource-poor settings: evidence from Ethiopia

Community-based reproductive health services (CBRHS) have been in implementation in Ethiopia for over a decade. This paper assesses the impact of such programmes on contraceptive use. The data were obtained from the 2000 Ethiopian Demographic and Health Survey (DHS) and the 2003 Contraceptive Prevalence Survey (CPS). While the 2000 DHS contained a nationally representative random sample of women of reproductive age, the 2003 CPS focused on areas with active CBRHS programmes. The findings indicate that expanding the current CBRHS programme has the potential of doubling the current national contraceptive prevalence rate.