What works in family planning interventions: a systematic review

Generating and capitalizing on the demographic dividend potential in sub-Saharan Africa: a conceptual framework from a systematic literature review

Background: Africa will double its population by 2050 and more than half will be below age 25. The continent has a unique opportunity to boost its socioeconomic welfare. This systematic literature review aims to develop a conceptual framework that identifies policies and programs that have provided a favorable environment for generating and harnessing a demographic dividend. This framework can facilitate sub-Saharan African countries' understanding of needed actions to accelerate their demographic transition and capitalize on their demographic dividend potential. Methods: The search strategy was structured around three concepts: economic development, fertility, and sub-Saharan Africa. Databases used included PubMed and EconLit. An inductive approach was employed to expand the reference base further. Data were extracted using literature records following a checklist of items to include when reporting a systematic review suggested in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Results: The final review consisted of 78 peer-reviewed articles, ten reports from the gray literature, and one book. Data were categorized according to relevant demographic dividend typology: pre-dividend and early-dividend. The results from the literature review were synthesized into a framework consisting of five sectors for pre-dividend countries, namely 1) Governance and Economic Institutions, 2) Family Planning, 3) Maternal and Child Health, 4) Education, and 5) Women's Empowerment. An additional sector, 6) Labor Market, is added for early-dividend countries. These sectors must work together to attain a demographic dividend. Conclusions: A country's demographic transition stage must guide policy and programs. Most sub-Saharan African countries have prioritized job creation and employment for youth, yet their efforts to secure a productive labor market require preliminary and complementary investments in governance, family planning, maternal and child health, education, and women's empowerment. Creating a favorable policy environment for generating and capitalizing on a demographic dividend can support their stated goals for development.

Impact of home-based family planning counselling and referral on modern contraceptive use in Karachi, Pakistan: a retrospective, cross-sectional matched control study

OBJECTIVES

To assess: (1) the impact of a reproductive health program on modern contraceptive use from baseline to program close; (2) the sustained impact from baseline to follow-up 36 months later; and (3) the exposure-adjusted impact at program close and follow-up.

DESIGN

Retrospective, cross-sectional matched control study.

SETTING

Karachi, Pakistan.

PARTICIPANTS

2561 married women aged 16-49 years.

INTERVENTIONS

The Willows Program, a community-based family planning counselling and referral program implemented from 2013 to 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was community-level modern contraceptive prevalence rate (mCPR), measured for January 2013 (baseline), June 2015 (program close) and at follow-up 36 months later. A secondary outcome was exposure-adjusted mCPR (among women reporting a family planning home visit) at program close and at follow-up.

RESULTS

There was no significant effect on community-level mCPR at program close (2.4 percentage point increase in intervention over comparison; 95% CI -2.2 to 7.0) or at follow-up (1.9 percentage point decrease; 95% CI -6.7 to 2.8). Only 18% of women in the intervention area reported receiving a family planning visit in the preceding 5 years. Among those reporting a visit, we observed a significant 10.3 percentage point increase (95% CI 4.6 to 15.9) from baseline to close, and a non-significant 2.0 percentage point increase (95% CI -3.8 to 7.8) from baseline to follow-up, relative to matched women in the comparison area. The cost per new modern method user was US$1089, while the cost per user-year during the intervention period was US$455.

CONCLUSIONS

The program had a positive short-term effect on women who received a family planning visit; however, this effect was not sustained. Program coverage was low and did not significantly increase community-level family planning use. Findings highlight the need to increase community coverage of high-quality counselling and contextually relevant interventions for family planning demand generation.

Reducing the Cost of Remoteness: Community-Based Health Interventions and Fertility Choices

Distance to health centers can represent a significant healthcare cost for poor households. Community-based health interventions and community health workers can be an alternative to deficient formal health care provision among remote populations. We analyze the effects on fertility outcomes of a large-scale community-based health worker program that aims to reach remote areas distant from health facilities in Madagascar. We use a triple difference model that exploits time and geographic variation in the program rollout and the geocoded household distance to the closest health facility. Our findings indicate that the program decreased the probability of conception among women in treated areas but did not have a differential effect among women living in remote areas. A potential mechanism underlying this fertility reduction is that the program increased women's modern contraceptive use.

The Effect of Improved Access to Family Planning on Postpartum Women: Protocol for a Randomized Controlled Trial

Background

The World Health Organization recommends that a woman waits at least 24 months after a live birth before getting pregnant again; however, an estimated 25% of birth intervals in low-income countries do not meet this recommendation for adequate birth spacing, and the unmet need for postpartum family planning (PPFP) services is high. Few randomized controlled trials have assessed the causal impact of access to PPFP services, and even fewer evaluations have investigated how such interventions may affect postpartum contraceptive use, birth spacing, and measures of health and well-being.

Objective

This protocol paper aims to describe a randomized controlled trial that is being conducted to identify the causal impact of an intervention to improve access to PPFP services on contraceptive use, pregnancy, and birth spacing in urban Malawi. The causal effect of the intervention will be determined by comparing outcomes for respondents who are randomly assigned to an intervention arm against outcomes for respondents who are randomly assigned to a control arm.

Methods

Married women aged 18-35 years who were either pregnant or had recently given birth were randomly assigned to either the intervention arm or control arm. Women assigned to the intervention arm received a package of services over a 2-year intervention period. Services included a brochure and up to 6 home visits from trained family planning counselors; free transportation to a high-quality family planning clinic; and financial reimbursement for family planning services, consultations, and referrals for services. Two follow-up surveys were conducted 1 and 2 years after the baseline survey.

Results

A total of 2143 women were randomly assigned to either the intervention arm (n=1026) or the control arm (n=1117). Data collection for the first follow-up survey began in August 2017 and was completed in February 2018. A total of 1773 women, or 82.73% of women who were eligible for follow-up, were successfully contacted and reinterviewed at the first follow-up. Data collection for the second follow-up survey began in August 2018 and was completed in February 2019. A total of 1669 women, or 77.88% of women who were eligible for follow-up, were successfully contacted and reinterviewed at the second follow-up. The analysis of the primary outcomes is ongoing and is expected to be completed in 2021.

Conclusions

The results of this trial seek to fill the current knowledge gaps in the effectiveness of family planning interventions on improving fertility and health outcomes. The findings also show that the benefits of improving access to family planning are likely to extend beyond the fertility and health domain by improving other measures of women’s well-being.

Trial Registration

American Economics Association Registry Trial Number AEARCTR-0000697; https://www.socialscienceregistry.org/trials/697 Registry for International Development Impact Evaluations (RIDIE) Trial Number RIDIE-STUDY-ID-556784ed86956; https://ridie.3ieimpact.org/index.php?r=search/detailView&id=320

International Registered Report Identifier (IRRID)

DERR1-10.2196/16697

'I am the master key that opens and locks': Presentation and application of a conceptual framework for women's and girls' empowerment in reproductive health

RATIONALE

A renewed focus on women's and girls' empowerment in the era of Sustainable Development Goals reflects the belief that empowerment is central to health and development. Sexual and reproductive health (SRH) outcomes, including pregnancy and contraceptive use, may contribute to and result from empowerment. However, enhanced understanding of how women become empowered for SRH requires clear conceptualization of empowerment.

OBJECTIVE

We aimed to assess the applicability of a proposed framework for women's and girls' SRH empowerment (WGE-SRH) in sub-Saharan Africa. We sought to understand what shapes and motivates preferences for childbearing and contraception, exploring how women and girls navigate external pressures or rewards to exercise and achieve their reproductive goals.

METHODS

Grounded in the WGE-SRH framework, we conducted a qualitative study in four distinct contexts (Ethiopia, Kano and Anambra States in Nigeria, and Uganda). We implemented and analyzed 120 in-depth interviews and 38 focus group discussions with 440 women and men and translated results to refine the WGE-SRH framework.

RESULTS

Findings demonstrate the salience of women's internal motivations, including the social value and joys of motherhood, in shaping existence of reproductive choices. However, existence of choice was limited by couples' economic situations, pressures from providers, partners, and family members, and women's fears of contraceptive side effects or relationship dissolution. Despite these constraints, many found ways to exercise their reproductive choices through negotiation with partners, third party involvement in reproductive discussions, non-verbal communication, and covert use of contraception.

CONCLUSIONS

The WGE-SRH framework is useful for exploring SRH empowerment, embracing the multilevel, dynamic nature of empowerment, as a process transitioning from existence of choice (autonomy) to exercise of choice (self-efficacy, decision-making, negotiation), and, ultimately, to achievement of choice. Future research and programs related to SRH empowerment should distinguish between existence and exercise of choices to promote the health and well-being of women and girls.

Using qualitative evaluation components to help understand context: case study of a family planning intervention with female community health volunteers (FCHVs) in Nepal

BACKGROUND

Evaluations of health interventions are increasingly concerned with measuring or accounting for 'context'. How to do this is still subject to debate and testing, and is particularly important in the case of family planning where outcomes will inevitably be influenced by contextual factors as well as any intervention effects. We conducted an evaluation of an intervention where female community health volunteers (FCHVs) in Nepal were trained to provide better interpersonal communication on family planning. We included a context-orientated qualitative component to the evaluation. Here, we discuss the evaluation findings, specifically focusing on what was added by attending to the context. We explore and illustrate important dimensions of context that may also be relevant in future evaluation work.

METHODS

The evaluation used a mixed methods approach, with a qualitative component which included in-depth interviews with women of reproductive age, FCHVs, and family planning service providers. We conducted iterative, thematic analysis.

RESULTS

The life-history fertility and contraception narratives generated from the in-depth interviews contextualised the intervention, yielding nuanced data on contraceptive choices, needs, and areas for future action. For instance, it highlighted how women generally knew about effective contraceptive methods and were willing to use them: information was not a major barrier. Barriers instead included reports of providers refusing service when women were not in the fifth day of their menstrual cycle when this was unnecessary. Privacy and secrecy were important to some women, and risked being undermined by information sharing between FCHVs and health services. The qualitative component also revealed unanticipated positive effects of our own evaluation strategies: using referral slips seemed to make it easier for women to access contraception.

CONCLUSIONS

Life history narratives collected via in-depth interviews helped us understand pathways from intervention to effect from the user point of view without narrowly focusing only on the intervention, highlighting possible areas for action that would otherwise have been missed. By attending to context in a nuanced way in evaluations, we can build a body of evidence that not only informs future interventions within that context, but also builds better knowledge of contextual factors likely to be important elsewhere.

Impact of a social franchise intervention program on the adoption of long and short acting family planning methods in hard to reach communities in Myanmar

Myanmar has experienced slowly rising levels of contraceptive use in recent years. Between 2014 and 2016, Population Services International (PSI)/Myanmar implemented a multi-pronged intervention to increase contraceptive use by leveraging its social marketing clinics and providers, and providing additional community outreach. The aim of this study is to explore trends over time in contraceptive uptake and assess whether exposure to the PSI program was associated with women adopting a method. Baseline and end line data were collected using a repeated cross-sectional survey of married women of reproductive age in 2014 and 2016. We find that use of the implant and intrauterine device (IUD) has increased among contraceptive users over time, although there was no significant association for short-term methods. There was also an increase in all types of method use between time periods compared to non-users of contraception. Women who reported seeing a PSI contraception pamphlet had increased odds of having adopted an IUD or implant in the study period. This suggests that interventions that address both supply and demand side barriers to contraception can have an impact on contraceptive uptake, especially more effective long acting methods.

Covert use of contraception in three sub-Saharan African countries: a qualitative exploration of motivations and challenges

BACKGROUND

The balance between increasing men's participation in family planning and rights-based initiatives favoring women's empowerment is highlighted with the issue of covert use of contraception. While covert use has been documented in low- and middle-income countries as a way for women to obtain contraception in light of partner opposition, little is known about women's decision-making processes, actions, and potential consequences of discreet contraceptive use. We aimed to understand women's choices to use contraception covertly and the challenges they faced in concealing their use across three sub-Saharan African countries.

METHODS

Women aged 15-49 and their male partners were purposively sampled from urban and rural sites in Ethiopia, Northern and Southern Nigeria, and Uganda for 120 in-depth interviews and 38 focus group discussions. Semi-structured interviews explored women's and girls' empowerment surrounding sex, childbearing, and contraception. Interviews were conducted in local languages, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data; covert use codes were reviewed and matrices were created based on themes and sub-themes.

RESULTS

Findings comprised three thematic areas: the practice of covert contraceptive use and reasons for using covertly; challenges for women who use contraception covertly; and consequences of disclosure or being discovered. While some women initiated using contraception covertly due to tensions within relationships or to keep peace within the home due to known partner opposition, others did not consider family planning to be a male responsibility. Though covert use was commonly discussed, it was also socially sanctioned, and portrayed as an act of female disobedience that questioned the social order of patriarchy. Further challenges of using covertly included lack of financial and social support, and suspicions surrounding delayed fertility and contraceptive-related side effects. Repercussions comprised increased suspicion, threats, or violence, though some women reported improved couple communication with disclosure.

CONCLUSIONS

Results indicate that while covert use of contraception is common, continued covert use is challenging, especially when side effects manifest. Covert use may further suggest women taking independent action, symbolizing some level of empowerment. Results underscore the importance of disentangling unique reasons for covert use and the severity of repercussions of disclosure.

Using Systematic Anomalous Case Analysis to Examine Sexual and Reproductive Health Outcomes in the Philippines

The Philippines is characterized by sustained economic growth and political stability, yet sexual and reproductive health indicators have stalled or even worsened in recent decades. We employed an innovative, mixed-methods approach-Systematic Anomalous Case Analysis-to gain insights into these worsening trends by examining sexual and reproductive decision-making among a cohort of young adults in Metro Cebu, Philippines. We first analyzed longitudinal data (1998-2009) to predict reproductive outcomes (i.e., age of first sex, number of living children) among participants in the Cebu Longitudinal Health and Nutrition Survey to identify cases (predicted and anomalous) with whom we subsequently conducted qualitative, in-depth interviews in 2013-14 (n = 48). Analysis of the qualitative data revealed unique social and contextual factors that shaped patterns of sexual and contraceptive decision-making across three, distinct reproductive life stages: (1) at first sex, (2) after the birth of first child, and (3) after the birth of several children. However, gendered roles and expectations exerted strong influences on sexual and reproductive outcomes across these life stages. Finally, we identified two constructs from our qualitative analysis-sexual fluidity and sexual agency-that deserve further examination and integration into theoretical and empirical models of sexual and reproductive decision-making.

Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: A cross-sectional study

Background

A novel indicator, ‘percentage of women of reproductive age who are sexually active and who have their demands for FP satisfied with modern contraceptive methods (mDFPS)’, was developed in 2012 to accelerate the reduction of unmet needs of family planning (FP). In Jordan, unmet needs for modern contraception remain high. To address this situation, this study measured the mDFPS and identified its associated factors in rural Jordan.

Methods

This cross-sectional study included married women of reproductive age (15–49 years) from ten villages in Irbid Governorate, Jordan, where advanced health facilities are difficult to reach. A two-stage stratified sampling with random sampling at the household stage was used for this field survey which was conducted between September and October 2016. Univariate analysis was used to assess the differences between mDFPS and unmet mDFPS groups. Logistic regression analysis was performed to identify the correlates of mDFPS.

Results

Of 1019 participants, 762 were identified as needing modern contraception. mDFPS coverage accounted for 54.7%. The most significant factors associated with mDFPS were the husband’s agreement on FP (adjusted odds ratio [AOR]: 15.43, 95% confidence interval [CI]: 5.26–45.25), knowledge of modern contraceptives (AOR: 8.76, 95% CI: 5.72–13.40), and lack of awareness of the high risk of conception in the postpartum period (AOR: 2.21, 95% CI: 1.41–3.47). Duration of current residence, receipt of FP counselling at health centres and number of living children were also correlated. In addition, 95.3% of local women were aware of the presence of health centres that were mostly located in a 10-minute walking distance.

Conclusion

To increase mDFPS, this study suggested that accelerating male involvement in FP decision-making is necessary through community-based health education. Furthermore, expanding FP services in village health centres and improving the quality of FP counselling in public health facilities are required to correct misconceptions about modern methods among rural women.

Comparing simulated client experiences with phone survey self-reports for measuring quality of information given in family planning counseling: The case of depot medroxyprogesterone acetate – subcutaneous (DMPA-SC) in Nigeria

Background: The quality of family planning services can have important implications for uptake and continued method use. The aim of this analysis is to examine aspects of quality related to information provided for a new injectable contraceptive method, DMPA-SC (depot medroxyprogesterone acetate – subcutaneous, known as Sayana Press®), service provision and contraceptive services more broadly in Nigeria. Methods: We compared self-reports from follow-up phone surveys with users to simulated client interactions that were designed to measure the same concepts. Through mixed-methods, we sought to more deeply understand the biases associated with different data collection methods that ultimately lead to different conclusions regarding quality of information provided in contraceptive services, and to further assess to what extent these methods were suitable for detecting differences in quality across sub-groups using the case of married versus unmarried women. Results: We found that simulated clients reported lower levels of informational quality across all comparable quality indicators than phone survey respondents attending the same facilities. Both methods were able to detect differential treatment by marital status. Conclusions: A mixed-methods approach can provide differential insights into informational quality of family planning services, especially when aiming to understand both objective and subjective aspects of quality.

Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix

When designing a family planning (FP) strategy, decision-makers can choose from a wide range of interventions designed to expand access to and develop demand for FP. However, not all interventions will have the same impact on increasing modern contraceptive prevalence (mCP). Understanding the existing evidence is critical to planning successful and cost-effective programs. The Impact Matrix is the first comprehensive summary of the impact of a full range of FP interventions on increasing mCP using a single comparable metric. It was developed through an extensive literature review with input from the wider FP community, and includes 138 impact factors highlighting the range of effectiveness observed across categories and subcategories of FP interventions. The Impact Matrix is central to the FP Goals model, used to project scenarios of mCP growth that help decision-makers set realistic goals and prioritize investments. Development of the Impact Matrix, evidence gaps identified, and the contribution to FP Goals are discussed.

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

Background

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

Methods

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

Results

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

Conclusions

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

The effects of community-based distribution of family planning services on contraceptive use: The case of a national scale-up in Malawi

RATIONALE

Although many sub-Saharan African countries have scaled-up pilot projects of community-based distribution (CBD) of family planning services, the effects of the scaled-up CBDs on contraceptive use remain unclear.

OBJECTIVE

We leveraged a national scale-up of Malawi's Learning and Innovation Population and Family Planning pilot to evaluate the effects of a scale-up of CBDs on contraceptive use. We also investigated whether education and income, two important determinants of contraceptive use behaviors, moderate the effects of the scaled-up CBDs.

METHOD

We used the 2000/2004 and 2010/2016 Malawi Demographic and Health Surveys (N = 57,978) and difference-in-differences analyses to estimate the effects of the 2005 national scale-up of CBDs on modern contraceptive use. We used rural and urban communities as the intervention and comparison groups because the national CBDs were implemented only in rural communities. Contraceptive use is defined as the current use of any modern contraceptive method (e.g., pills) and was modelled using multilevel logistic regression.

RESULTS

Prior to the implementation of the national scale CBDs (2000/2004), the probability of using contraceptives was 21.5% in rural communities and 26.3% in urban communities. After the scale-up (2010/2016), the probability of using contraceptives increased in both rural and urban communities but was greater in rural communities (44.9% vs. 42.9%). The effect attributable to the national scale CBDs was 6.8 percentage points (95% CI [3.3, 9.7]). The effects of the national CBDs were greater among uneducated and low-income women.

CONCLUSIONS

These findings suggest that national CBDs increase overall contraceptive use, particularly in rural communities, and that poor and uneducated women benefit more from family planning interventions that reduce communication and financial barriers.

Mobile Helpline and Reversible Contraception: Lessons From a Controlled Before-and-After Study in Rural India

BACKGROUND

Researchers and activists have expressed concerns over the lack of availability and nonuse of reversible, modern, contraceptive methods in India for decades. New attempts to increase access, availability, and acceptance of reversible contraceptives need to be developed, instead of relying solely on female sterilization. Mobile health (mHealth) initiatives may offer one way to serve underprivileged populations who face challenges in sexual and reproductive health (SRH) in countries such as India.

OBJECTIVE

This study aimed to examine the outcome of an mHealth intervention for enhancing knowledge of, and practices related to, reversible contraceptives in rural Western India.

METHODS

We implemented a nonrandomized controlled trial (before-and-after study in an intervention area and a control area) in the Indian state of Maharashtra. The intervention in this case was a mobile-based SRH helpline provided by a nongovernmental organization (NGO). Baseline and follow-up surveys were carried out in two government-run primary health center areas, one each in the intervention and control area, and 405 respondents were surveyed in the two rounds. An interview-based structured questionnaire suitable for a low-literacy environment was used to collect data. The effect of the intervention was estimated using logistic regression, adjusted for gender, by calculating robust standard errors to take into account the clustering of individuals by the area (intervention or control). In each regression model, the effect of intervention was estimated by including a term for interaction between the intervention area and the period before and after the intervention. The exponent of the regression coefficient of the interaction term corresponding to the period after the intervention, along with the 95% CI, is reported here. The odds ratio for the control village multiplied by this exponent gives the odds ratio for the intervention village. Calls received in the intervention were recorded and their topics analyzed.

RESULTS

The current use of reversible contraception (18% increase in intervention area vs 2% increase in control area; 95% CI) has seen changes. The proportion of respondents who had heard of contraception methods from an NGO rose in the intervention area by 23% whereas it decreased in the control area by 1% (95% CI). However, the general level of awareness of reversible contraception, shown by the first contraceptive method that came to respondents' mind, did not improve. Demand for wider SRH information beyond contraception was high. Men and adolescents, in addition to married women, made use of the helpline.

CONCLUSIONS

A mobile helpline that one can confidentially approach at a time most convenient to the client can help provide necessary information and support to those who need reversible contraception or other sexual health information. Services that integrate mHealth in a context-sensitive way to other face-to-face health care services add value to SRH services in rural India.

Meeting the demand of women affected by ongoing crisis: Increasing contraceptive prevalence in North and South Kivu, Democratic Republic of the Congo

Context

Over 20 years of conflict in the DRC, North and South Kivu have experienced cycles of stability and conflict, resulting in a compromised health system and poor sexual and reproductive health outcomes. Modern contraceptive use is low (7.5%) and maternal mortality is high (846 deaths per 100,000 live births). Program partners have supported the Ministry of Health (MOH) in North and South Kivu to provide good quality contraceptive services in public health facilities since 2011.

Methods

Cross-sectional population-based surveys were conducted in the program areas using a two-stage cluster sampling design to ensure representation in each of six rural health zones. Using MOH population estimates for villages in the catchment areas of supported health facilities, 25 clusters in each zone were selected using probability proportional to size. Within each cluster, 22 households were systematically selected, and one woman of reproductive age (15–49 years) was randomly selected from all eligible women in each household.

Results

Modern contraceptive prevalence among women in union ranged from 8.4% to 26.7% in the six health zones; current use of long-acting or permanent method (LAPM) ranged from 2.5% to 19.8%. The majority of women (58.9% to 90.2%) reported receiving their current method for the first time at a health facility supported by the program partners. Over half of women in four health zones reported wanting to continue their method for five years or longer.

Conclusion

Current modern contraceptive use and LAPM use were high in these six health zones compared to DRC Demographic and Health Survey data nationally and provincially. These results were accomplished across all six health zones despite their varied socio-demographic characteristics and different experiences of conflict and displacement. These findings demonstrate that women in these conflict-affected areas want contraception and will choose to use it when good quality services are available to them.

Does community mobilisation improve awareness, approval and uptake of family planning methods among women of reproductive age in Ebonyi State? Experience from a quasi-experimental study

Introduction

family planning programmes have helped in increasing the prevalence of contraceptive use and reducing total fertility rate in developing countries from six to three births per woman. However, its uptake is lower in the rural areas compared to urban areas. This study seeks to elucidate the effect of community mobilisation on awareness, approval and use of family planning among women of reproductive age in the rural areas of Ebonyi state, Nigeria.

Methods

we conducted a quasi-experimental study among women aged 15 to 49 years in two rural communities in Ebonyi state. Using simple random method, we recruited 484 women for the study. We used pre-tested interviewer-administered questionnaire to collect information from the participants. Community awareness and distribution of information, education and communication materials were carried out within one month. We estimated the effect of the intervention on the level of awareness, approval and uptake of family planning methods.

Results

level of awareness increased by 19% (p<0.001) while uptake of family planning increased by 16.7% (p<0.001) in the intervention group. The approval rate was higher in the intervention group compared to the control group (p=0.008). The most commonly used method of family planning was the natural method in intervention and control arms.

Conclusion

although uptake of family planning increased significantly in the study population, the rate is generally low. Given the critical role of the community in family planning programmes, community mobilisation may be deployed to increase uptake of family planning in similar rural communities.

Health care providers' perspectives on delivering gender equity focused family planning program for young married couples in a cluster randomized controlled trial in rural Maharashtra, India

Background: There is increasing programming and research on male engagement and gender-equity (GE) counselling in family planning (FP) services. However, there is a lack of data on healthcare provider’s perspectives on delivering these interventions. The objective of the paper is to present providers’ perspectives on delivering a GE-focused FP intervention, CHARM, to married couples in rural India.

Methods:  In-depth interviews were carried out with 22 male village health care providers who were delivering a GE-focused FP intervention, CHARM, to 428 husbands (247 couples) rural Maharashtra, India. Providers were interviewed on their experiences and perspectives during delivery of CHARM. Major domains were identified during a thematic analysis.

Results: Local male health providers are interested and can be engaged in delivering a GE-focused FP intervention. Providers believed that the CHARM intervention improves couples’ communication, contraceptive use and strengthened their own capacity to provide FP services in accordance with national FP programmatic efforts. Providers found the low-tech flipchart including pictures and information helpful in supporting their service provision. Providers reported some challenges including lack of privacy and space for counselling, limited access to contraceptive options beyond pill and condom, numerous myths and misconceptions about contraceptives. Providers also reported persistent social norms related to expectancy of pregnancy early in marriage, and son preference.

Conclusions: Providers in rural areas with high fertility and related maternal health complications are interested in and can successfully implement a GE-focused FP intervention. Future efforts using this approach may benefit from greater focus to support broader array of spacing contraceptives particularly among first time parents, none or one child parents. There is a need to better support engagement of wives possibly through female provider led sessions parallel to male programs, i.e. gender synchronized rather than couples’ sessions.

Trialregistration: ClinicalTrials.gov  NCT01593943, May 8, 2012.

Comparing simulated client experiences with phone survey self-reports for measuring the quality of family planning counseling: The case of depot medroxyprogesterone acetate – subcutaneous (DMPA-SC) in Nigeria

Background: The quality of family planning services can have important implications for uptake and continued method use. The aim of this analysis is to examine aspects of quality for a new injectable contraceptive method, DMPA-SC (depot medroxyprogesterone acetate – subcutaneous, known as Sayana Press®), service provision and contraceptive services more broadly in Nigeria. Methods: We compared self-reports from follow-up phone surveys with users to simulated client interactions that were designed to measure the same concepts. Through mixed-methods, we sought to more deeply understand the biases associated with different data collection methods that ultimately lead to different conclusions regarding quality of contraceptive services, and to further assess to what extent these methods were suitable for detecting differences in quality across sub-groups using the case of married versus unmarried women. Results: We found that simulated clients reported lower levels of quality across all comparable quality indicators than phone survey respondents attending the same facilities. Both methods were able to detect differential treatment by marital status. Conclusions: A mixed-methods approach can provide differential insights into quality of family planning services, especially when aiming to understand both objective and subjective aspects of quality.

Knowledge and use of family planning among men in rural Uganda

BACKGROUND

Unmet need for family planning exceeds 33% in Uganda. One approach to decreasing unmet need is promoting male involvement in family planning. Male disapproval of use of family planning by their female partners and misconceptions about side effects are barriers to family planning globally and in Uganda in particular. Researchers have conducted a number of qualitative studies in recent years to examine different aspects of family planning among Ugandan men. The present study aimed to quantify men's knowledge of family planning in rural Uganda to understand how better to involve men in couples' contraceptive decision-making, particularly in low-resource settings.

METHODS

Data were derived from in-person, researcher-administered surveys of men in a rural agrarian district in Uganda (N = 178). Participant demographics and knowledge of family planning methods, side effects, and use were queried. Descriptive statistics were used for analysis.

RESULTS

Men were 34 years of age on average (range 18-71) and about half (56%) had a primary school education or less. Ninety-eight percent reported any knowledge of family planning, with 73% of men reporting obtaining information via radio and only 43% from health workers. The most common method known by men was the male condom (72%), but more than half also knew of injections (54%) and pills (52%). Relatively few men reported knowing about the most effective reversible contraceptive methods, intrauterine devices and implants (both 16%). Men identified many common contraceptive side-effects, such as vaginal bleeding (31%), and misconceptions about side effects, such as increased risk of infertility and birth defects, were relatively uncommon (both < 10%). About half of all men reported ever using a family planning method (53%), and 40% reported current use.

CONCLUSIONS

This study's quantitative results build on those of recent qualitative studies and provide information about the types of family planning information men are lacking and avenues for getting this information to them.

Interventions to improve the person-centered quality of family planning services: a narrative review

Person-centered care, a key component of quality of care, is receiving increased attention for maternal and reproductive health. While many interventions have aimed to improve person-centered care for family planning, there is no known narrative review of person-centered-focused interventions in family planning and the outcomes of these interventions. This narrative review fills this gap by conducting a rigorous analysis of interventions that address person-centered care and measure family planning related outcomes, including quality, knowledge and use/continuation. The search of the published and grey literature, from 1990 to 2015 identified 5530 papers, of which 25 were ultimately included in the analysis (after exclusion criteria was applied). We grouped these interventions under seven domains of person-centered care: dignity, autonomy, privacy/confidentiality, communication, social support, supportive care, and trust. We find that person-centered interventions had high success in improving perceptions of quality and knowledge of family planning among clients; however, results were less consistent in improving family planning uptake and continuation. These findings will help program and policy makers develop interventions that incorporate person-centered components to have the highest likelihood for success in improving clients' experiences and family planning use.

Developing a Digital Marketplace for Family Planning: Pilot Randomized Encouragement Trial

Background

Family planning is an effective tool for preventing death among women who do not want to become pregnant and has been shown to improve newborn health outcomes, advance women’s empowerment, and bring socioeconomic benefits through reductions in fertility and population growth. Yet among the populations that would benefit the most from family planning, uptake remains too low. The emergence of digital health tools has created new opportunities to strengthen health systems and promote behavior change. In this study, women with an unmet need for family planning in Western Kenya were randomized to receive an encouragement to try an automated investigational digital health intervention that promoted the uptake of family planning.

Objective

The objectives of the pilot study were to explore the feasibility of a full-scale trial—in particular, the recruitment, encouragement, and follow-up data collection procedures—and to examine the preliminary effect of the intervention on contraception uptake.

Methods

This pilot study tested the procedures for a randomized encouragement trial. We recruited 112 women with an unmet need for family planning from local markets in Western Kenya, conducted an eligibility screening, and randomized half of the women to receive an encouragement to try the investigational intervention. Four months after encouraging the treatment group, we conducted a follow-up survey with enrolled participants via short message service (SMS) text message.

Results

The encouragement sent via SMS text messages to the treatment group led to differential rates of intervention uptake between the treatment and control groups; however, uptake by the treatment group was lower than anticipated (19/56, 33.9% vs 1/56, 1.8%, in the control group). Study attrition was also substantial. We obtained follow-up data from 44.6% (50/112) of enrolled participants. Among those in the treatment group who tried the intervention, the instrumental variables estimate of the local average treatment effect was an increase in the probability of contraceptive uptake of 41.0 percentage points (95% uncertainty interval −0.03 to 0.85).

Conclusions

This randomized encouragement design and study protocol is feasible but requires modifications to the recruitment, encouragement, and follow-up data collection procedures.

Trial Registration

ClinicalTrials.gov NCT03224390; https://clinicaltrials.gov/ct2/show/NCT03224390 (Archived by WebCite at http://www.webcitation.org/70yitdJu8)

A demographic dividend of the FP2020 Initiative and the SDG reproductive health target: Case studies of India and Nigeria

Background: The demographic dividend, defined as the economic growth potential resulting from favorable shifts in population age structure following rapid fertility decline, has been widely employed to advocate improving access to family planning. The current framework focuses on the long-term potential, while the short-term benefits may also help persuade policy makers to invest in family planning.

Methods: We estimate the short- and medium-term economic benefits from two major family planning goals: the Family Planning 2020 (FP2020)’s goal of adding 120 million modern contraceptive users by 2020; Sustainable Development Goals (SDG) 3.7 of ensuring universal access to family planning by 2030. We apply the cohort component method to World Population Prospects and National Transfer Accounts data. India and Nigeria, respectively the most populous Asian and African country under the FP2020 initiative, are used as case studies.

Results: Meeting the FP2020 target implies that on average, the number of children that need to be supported by every 100 working-age people would decrease by 8 persons in India and 11 persons in Nigeria in 2020; the associated reduction remains at 8 persons in India, but increases to 14 persons in Nigeria by 2030 under the SDG 3.7. In India meeting the FP2020 target would yield a saving of US$18.2 billion (PPP) in consumption expenditures for children and youth in the year 2020 alone, and that increased to US$89.7 billion by 2030. In Nigeria the consumption saved would be US$2.5 billion in 2020 and $12.9 billion by 2030.

Conclusions: The tremendous economic benefits from meeting the FP2020 and SDG family planning targets demonstrate the cost-effectiveness of investment in promoting access to contraceptive methods. The gap already apparent between the observed and targeted trajectories indicates tremendous missing opportunities. Accelerated progress is needed to achieve the FP2020 and SDG goals and so reap the demographic dividend.

Body Mapping to Explore Reproductive Ethno-Physiological Beliefs and Knowledge of Contraception in Timor-Leste

Maternal mortality remains a significant public health challenge for Timor-Leste. Although access to quality family planning measures may greatly reduce such deaths, consideration of indigenous perceptions, and how they influence reproductive health decision-making and behavior, is crucial if health services are to provide initiatives that are accepted and helpful in improving reproductive health outcomes. We aimed to demonstrate that body mapping is an effective method to traverse language and culture to gain emic insights and indigenous worldviews. The authors' two qualitative research projects (2013 and 2015) used a decolonizing methodology in four districts of Timor-Leste, body mapping with 67 men and 40 women to illuminate ethno-physiology and indigenous beliefs about conception, reproduction, and contraception. Body mapping provided a beneficial conduit for identifying established indigenous reproductive perceptions, understandings, and vocabulary, plus fears surrounding contraception. This may inform health service provision and engagement, ultimately improving the reproductive health of community members.

Awareness and opinions regarding contraception by women of reproductive age in North-West Nigeria

Introduction

North-west Nigeria is a traditionally high fertility setting. Increasing attention is being channeled into scaling up the various interventions that can reduce high fertility, including enhancing contraceptive uptake among women of reproductive age. However, in order to improve demand for contraception, understanding the level of awareness, knowledge and perception of WRA to contraceptive use is essential. This study examines the level of knowledge and perception of WRA to contraceptive use.

Methods

A descriptive cross-sectional study was carried out in December 2016 in Kebbi and Sokoto states, North-west Nigeria. Semi-structured questionnaires were administered to 500 women between the ages of 15-49 years in 4 randomly selected local government areas across the states. Data analysis included descriptive and bi-variate statistics.

Results

Only 43.8% claimed to be currently using a modern form of contraception; 82.4% were aware of at least one form of contraception, while health personnel formed the major source of information. The most popular and least common modern contraceptive methods were the male condom (86.8%) and vasectomy (26.6%) respectively. A higher proportion of married respondents (88.8%) than those presently single (68.8%) had good knowledge of contraceptives. Perception of contraceptives was mixed, with majority believing that contraceptives should be made available to every woman, despite stating that it contradicted their religious beliefs.

Conclusion

These results underline the need for policy makers to focus on improving the knowledge of younger age groups on contraceptives and include other information channels such as peer-to-peer discussions to increase awareness.

Expectant fathers' participation in antenatal care services in Papua New Guinea: a qualitative inquiry

Background

The importance of engaging men in maternal and child health programs is well recognised internationally. In Papua New Guinea (PNG), men’s involvement in maternal and child health services remains limited and barriers and enablers to involving fathers in antenatal care have not been well studied. The purpose of this paper is to explore attitudes to expectant fathers participating in antenatal care, and to identify barriers and enablers to men‘s participation in antenatal care with their pregnant partner in PNG.

Methods

Twenty-eight focus group discussions were conducted with purposively selected pregnant women, expectant fathers, older men and older women across four provinces of PNG. Fourteen key informant interviews were also conducted with health workers. Qualitative data generated were analysed thematically.

Results

While some men accompany their pregnant partners to the antenatal clinic and wait outside, very few men participate in antenatal consultations. Factors supporting fathers’ participation in antenatal consultations included feelings of shared responsibility for the unborn child, concern for the mother’s or baby’s health, the child being a first child, friendly health workers, and male health workers. Sociocultural norms and taboos were the most significant barrier to fathers’ participation in antenatal care, contributing to men feeling ashamed or embarrassed to attend clinic with their partner. Other barriers to men’s participation included fear of HIV or sexually transmitted infection testing, lack of separate waiting spaces for men, rude treatment by health workers, and being in a polygamous relationship. Building community awareness of the benefits of fathers participating in maternal and child health service, inviting fathers to attend antenatal care if their pregnant partner would like them to, and ensuring clinic spaces and staff are welcoming to men were strategies suggested for increasing fathers’ participation in antenatal care.

Conclusion

This study identified significant sociocultural and health service barriers to expectant fathers’ participation in antenatal care in PNG. Our findings highlight the need to address these barriers – through health staff training and support, changes to health facility layout and community awareness raising – so that couples in PNG can access the benefits of men’s participation in antenatal care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1759-4) contains supplementary material, which is available to authorized users.

The effects of health facility access and quality on family planning decisions in urban Senegal

Research in developing countries is rarely focused on examining how supply side factors affect family planning decisions due to a lack of facility-level data. When these data exist, analyses tend to focus on rural environments. In this paper, we study the effects that health facility access and quality have on contraceptive use and desired number of children for women in urban Senegal. Unlike related studies focusing on rural environments, we find no evidence that greater access to health facilities and pharmacies increases contraceptive use among urban women. However, we do find that contraceptive use among urban women is higher with greater facility quality. For example, we find that increasing the proportion of pharmacies employing multiple pharmacists from 0% to 50% would increase contraceptive use by 6.0 percentage points, and increasing the proportion of facilities with family planning guidelines/protocols from 50% to 100% would increase use by 2.1 percentage points.

A demographic dividend of the FP2020 Initiative and the SDG reproductive health target: Case studies of India and Nigeria

Background: The demographic dividend, defined as the economic growth potential resulting from favorable shifts in population age structure following rapid fertility decline, has been widely employed to advocate improving access to family planning. The current framework focuses on the long-term potential, while the short-term benefits may also help persuade policy makers to invest in family planning. Methods: We estimate the short- and medium-term economic benefits from two major family planning goals: the Family Planning 2020 (FP2020)’s goal of adding 120 million modern contraceptive users by 2020; Sustainable Development Goals (SDG) 3.7 of ensuring universal access to family planning by 2030. We apply the cohort component method to World Population Prospects and National Transfer Accounts data. India and Nigeria, respectively the most populous Asian and African country under the FP2020 initiative, are used as case studies. Results: Meeting the FP2020 target implies that on average, the number of children that need to be supported by every 100 working-age people would decrease by 8 persons in India and 11 persons in Nigeria in 2020; the associated reduction remains at 8 persons in India, but increases to 14 persons in Nigeria by 2030 under the SDG 3.7. In India meeting the FP2020 target would yield a saving of US$18.2 billion (PPP) in consumption expenditures for children and youth in the year 2020 alone, and that increased to US$89.7 billion by 2030. In Nigeria the consumption saved would be US$2.5 billion in 2020 and $12.9 billion by 2030. Conclusions: The tremendous economic benefits from meeting the FP2020 and SDG family planning targets demonstrate the cost-effectiveness of investment in promoting access to contraceptive methods. The gap already apparent between the observed and targeted trajectories indicates tremendous missing opportunities. Accelerated progress is needed to achieve the FP2020 and SDG goals and so reap the demographic dividend.

Awareness and use of family planning methods among iTaukei women in Fiji and New Zealand

OBJECTIVE

iTaukei women's awareness and practice of family planning methods was investigated in New Zealand and Fiji to ascertain differences in behaviour within the context of changing developmental settings.

METHODS

The study was cross-sectional in nature and recruited women aged 18 years and over from three suburbs in Suva, Fiji, and five cities in New Zealand.

RESULTS

Overall, 352 women participated in the study, 212 in Fiji and 140 in New Zealand. The study found that living in New Zealand was significantly associated with lower odds of being aware of family planning (OR 0.4, 95%CI 0.2-0.9, p=0.029) and using family planning methods (OR 0.5, 95%CI 0.2-0.9, p=0.027). Tertiary education was found to increase the odds of being aware (OR 2.8, 95%CI 1.3-6.2, p=0.009) and of using (OR 3.9, 95%CI 1.9-7.8, p=0.000) family planning.

CONCLUSIONS

Despite the greater availability of services and higher standards of living experienced in New Zealand compared with Fiji, there was no improvement in awareness and use of family planning among New Zealand participants. Implications for public health: Reduced awareness and use of family planning in New Zealand indicates a need for better targeting of services among minority Pacific ethnic groups.

The Senegal urban reproductive health initiative: a longitudinal program impact evaluation

Objectives

This paper presents the impact of key components of the Senegal Urban Reproductive Health Initiative, including radio, television, community-based activities, Muslim religious-leader engagement and service quality improvement on modern contraceptive use by all women and the sub-sample of poor women.

Study design

This study uses baseline (2011) and endline (2015) longitudinal data from a representative sample of urban women first surveyed in 2011 to examine the impact of the Initiative's demand- and supply-side activities on modern contraceptive use.

Results

By endline, there was increased exposure to radio and television programming, religious leaders speaking favorably about contraception, and community-based initiatives. In the same period, modern contraceptive use increased from 16.9% to 22.1% with a slightly larger increase among the poor (16.6% to 24.1%). Multivariate analyses demonstrate that women exposed to community-based activities were more likely to use modern contraception by endline (marginal effect (ME): 5.12; 95% confidence interval (CI): 2.50–7.74) than those not exposed. Further, women living within 1 km of a facility with family planning guidelines were more likely to use (ME: 3.54; 95% CI: 1.88–5.20) than women without a nearby facility with guidelines. Among poor women, community-based activities, radio exposure (ME: 4.21; 95% CI: 0.49–7.93), and living close to program facilities (ME: 4.32; 95% CI: 0.04–8.59) impacted use.

Conclusions

Community-based activities are important for reaching urban women, including poor women, to achieve increased contraceptive use. Radio programming is also an important tool for increasing demand, particularly among poor women. Impacts of other program activities on contraceptive use were modest.

Implications

This study demonstrates that community-based activities led to increased modern contraceptive use among all women and poor women in urban Senegal. These findings can inform future programs in urban Senegal and elsewhere in francophone Africa.

Impact of the Urban Reproductive Health Initiative on family planning uptake at facilities in Kenya, Nigeria, and Senegal

Background

The 2012 London Summit on Family Planning set ambitious goals to enable 120 million more women and adolescent girls to use modern contraceptives by 2020. The Urban Reproductive Health Initiative (URHI) was a Bill & Melinda Gates Foundation funded program designed to help contribute to these goals in urban areas in India, Kenya, Nigeria, and Senegal. URHI implemented a range of country-specific demand and supply side interventions, with supply interventions generally focused on improved service quality, provider training, outreach to patients, and commodity stock management. This study uses data collected by the Measurement, Learning & Evaluation (MLE) Project to examine the effectiveness of these supply-side interventions by considering URHI’s influence on the number of family planning clients at health facilities over a four-year period in Kenya, Nigeria, and Senegal.

Methods

The analysis used facility audits and provider surveys. Principal-components analysis was used to create country-specific program exposure variables for health facilities. Fixed-effects regression was used to determine whether family planning uptake increased at facilities with higher exposure. Outcomes of interest were the number of new family planning acceptors and the total number of family planning clients per reproductive health care provider in the last year.

Results

Higher program component scores were associated with an increase in new family planning acceptors per provider in Kenya (β = 18, 95% CI = 7–29), Nigeria (β = 14, 95% CI = 8–20), and Senegal (β = 7, 95% CI = 3–12). Higher scores were also associated with more family planning clients per provider in Kenya (β = 31, 95% CI = 7–56) and Nigeria (β = 26, 95% CI = 15–38), but not in Senegal.

Conclusions

Supply-side interventions have increased the number of new family planning acceptors at facilities in urban Nigeria, Kenya, and Senegal and the overall number of clients in urban Nigeria and Kenya. While tailoring to the local environment, programs seeking to increase family planning use should include components to improve availability and quality of family planning services, which are part of a rights-based approach to family planning programming.

Mass media exposure and modern contraceptive use among married West African adolescents

PURPOSE

The purpose of this study was to examine whether family planning (FP) messaging is reaching married adolescent women in West Africa, and whether such messaging is associated with increased contraceptive use.

MATERIALS AND METHODS

We utilised data from the 2010 Demographic and Health Surveys (DHS) for Burkina Faso and Senegal (women 15-49; N = 17,067 and N = 15,688, respectively). We used chi-square tests to evaluate whether FP messaging exposure (via TV, radio, and/or print) differed according to socio-demographic characteristics. Subsequent analysis focussed on married adolescents (15-19; N = 961 in Burkina Faso, N = 996 in Senegal) which utilised propensity score matching and multivariable logistic regression models to test the association between self-reported FP messaging exposure and modern contraceptive use, knowledge of a modern contraceptive method, and future intention to use contraception.

RESULTS

A higher proportion of women 15-49 who reported FP messaging exposure were urban, from higher wealth quintiles, and had higher education levels, compared with unexposed women. A smaller proportion of adolescents reported exposure compared to older age groups. Among married adolescents, there was a positive but non-significant association between FP messaging exposure and use of a modern contraceptive method in Senegal (adjusted odds ratio (aOR) = 2.3; 95% CI: 0.92, 5.73). No such association was found in Burkina Faso (aOR = 0.98; 95% CI: 0.43, 2.26).

CONCLUSIONS

Mass media campaigns are not reaching the most vulnerable populations in West Africa, such as adolescents and poorer rural women. Adapting mass media campaigns to address these gaps is important for increasing exposure to FP messaging.

Poor Knowledge and Nonuse of Long-Acting/Permanent Methods of Contraceptives in Six Districts in Indonesia

This analysis aimed at examining the association between the level of knowledge about long-acting/permanent methods of contraceptives (LAPM) and nonuse of LAPM among currently married, nonpregnant, and fecund women aged 15 to 49 years intending to limit childbearing. Data were derived from a cross-sectional study in Tuban, Kediri, and Lumajang District (East Java Province) and Lombok Barat, Lombok Timur, and Sumbawa District (Nusa Tenggara Barat Province) in June 2012. Information was obtained from 4323 respondents. Using multivariate logistic regression, we found that women with moderate levels of LAPM knowledge were less likely to use LAPM than women with high levels of knowledge (adjusted odds ratio [aOR] = 2.01, 95% CI = 1.51-2.68). Women with low level of LAPM knowledge were less likely to use LAPM than women with high levels of knowledge (aOR = 4.25, 95% CI = 3.37-5.36). Efforts to strengthen counseling services and increased provider knowledge and counselling skills are important to improve women's knowledge about and use of LAPM.

Improving family planning services delivery and uptake: experiences from the "Reversing the Stall in Fertility Decline in Western Kenya Project"

Objective

In this paper, we reflect on our experiences of implementing a multipronged intervention to improve sexual and reproductive health outcomes. The project used family planning as its entry point and was implemented in two high fertility counties—Busia and Siaya in Kenya. The intervention, implemented by a seven-member consortium, involved: family planning services delivery; regular training of service providers to deliver high quality services; monitoring and evaluation; strengthening of commodity chain delivery and forecasting; school-based and out-of-school based sexuality education; and advocacy and stakeholder engagements at the community, county and national levels.

Results

Over a 5-year period, the project contributed to raising demand for family planning considerably, evidenced in fertility decline. It also improved the capacity of family planning services providers, increased commitment and awareness of county government and other community stakeholders on the importance of investments in family planning. Our collaborations with organisations interested in sexual and reproductive health issues substantially enhanced the consortium’s ability to increase demand for, and supply of family planning commodities. These collaborations are proving useful in the continuity and sustainability of project achievements.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2821-4) contains supplementary material, which is available to authorized users.

Impact of men's perception on family planning demand and uptake in Nigeria

OBJECTIVE

Evidence from the last three Demographic and Health Surveys (DHS) in Nigeria shows slow progress in family planning (FP) uptake, despite programmatic interventions. While socioeconomic and religious barriers continue to exist, psychosocial factors such as negative contraceptive perceptions by male partners may influence both spousal FP demand and use. Therefore, this research investigates the influence of male partners' contraceptive perceptions on spousal FP demand and use.

METHODS

We analysed the couple dataset from the 2013 Nigeria DHS.

RESULTS

One in five men held the perception that contraceptive use is women's business whereas two in five men reported that women who use family planning may become promiscuous, especially older men, those with no formal education, Muslims and residents in rural areas and northern region. Results from regression models, controlling for relevant sociodemographic characteristics, show that men's perception that contraception is women's business did not significantly influence FP demand. However, their fear that women who use family planning may become promiscuous was associated with lower odds of FP demand (AOR: 0.86; 95% CI: 0.76-0.97) and increased the odds of traditional methods use (AOR: 1.34; 95% CI: 1.01-1.79).

CONCLUSION

The findings direct the need to adopt targeted approach focusing on couples, and reorient policy and program efforts for FP counselling and behavioural changes in men.

WHISPER or SHOUT study: protocol of a cluster-randomised controlled trial assessing mHealth sexual reproductive health and nutrition interventions among female sex workers in Mombasa, Kenya

INTRODUCTION

New interventions are required to reduce unintended pregnancies among female sex workers (FSWs) in low- and middle-income countries and to improve their nutritional health. Given sex workers' high mobile phone usage, repeated exposure to short messaging service (SMS) messages could address individual and interpersonal barriers to contraceptive uptake and better nutrition.

METHODS

In this two-arm cluster randomised trial, each arm constitutes an equal-attention control group for the other. SMS messages were developed systematically, participatory and theory-driven and cover either sexual and reproductive health (WHISPER) or nutrition (SHOUT). Messages are sent to participants 2-3 times/week for 12 months and include fact-based and motivational content as well as role model stories. Participants can send reply texts to obtain additional information. Sex work venues (clusters) in Mombasa, Kenya, were randomly sampled with a probability proportionate to venue size. Up to 10 women were recruited from each venue to enrol 860 women. FSWs aged 16-35 years, who owned a mobile phone and were not pregnant at enrolment were eligible. Structured questionnaires, pregnancy tests, HIV and syphilis rapid tests and full blood counts were performed at enrolment, with subsequent visits at 6 and 12 months.

ANALYSIS

The primary outcomes of WHISPER and SHOUT are unintended pregnancy incidence and prevalence of anaemia at 12 months, respectively. Each will be compared between study groups using discrete-time survival analysis.

POTENTIAL LIMITATIONS

Contamination may occur if participants discuss their intervention with those in the other trial arm. This is mitigated by cluster recruitment and only sampling a small proportion of sex work venues from the sampling frame.

CONCLUSIONS

The design allows for the simultaneous testing of two independent mHealth interventions for which messaging frequency and study procedures are identical. This trial may guide future mHealth initiatives and provide methodological insights into use of reciprocal control groups.

TRIAL REGISTRATION NUMBER

ACTRN12616000852459; Pre-results.

Increasing the uptake of long-acting and permanent methods of family planning: A qualitative study with village midwives in East Java and Nusa Tenggara Barat Provinces, Indonesia

OBJECTIVE

this analysis aims to explore midwives' insights into the provision of long-acting and permanent methods of contraception (LAPMs) in the selected areas of East Java and Nusa Tenggara Barat (NTB) Provinces, Indonesia.

DESIGN

a qualitative study using in-depth interviews was conducted with 12 village midwives from 12 villages, to explore their perceptions and experiences in delivering family planning services.

SETTING

the study was carried out in May-June 2013, as part of the baseline assessment in the Improving Contraceptive Method Mix (ICMM) study. We interviewed 12 village midwives working in 12 villages in six study districts: Tuban, Kediri, and Lumajang Districts in East Java Province; and Lombok Barat, Lombok Timur, and Sumbawa Districts in NTB Province.

MEASUREMENT

an interview guideline was used in all interviews. It covered several topics, such as community perceptions of LAPMs, availability of contraception and related equipment, availability of human resources, and midwives' efforts to improve LAPM coverage. All interviews were recorded and transcribed. Content and thematic analyses were carried out by grouping and coding the information based on the identified themes and topics.

FINDINGS

according to village midwives interviewed in this study, community-level acceptance of LAPMs has increased over time; however, some still prefer using short-acting methods for a long period. The reasons include lack of awareness about the benefits and side effects of LAPMs, fear of surgical procedures, rumored consequences (for example, that LAPMs would limit women's ability to perform hard physical labor), and religious beliefs. There were several challenges reported by village midwives in delivering LAPM services, such as confusion about midwives' eligibility to provide LAPM services, lack of Contraceptive Technology Update (CTU) and counseling trainings, and shortage of supporting equipment (such as exam tables and IUD and implant insertion kits). There were several strategies implemented by village midwives to improve LAPM use, including strengthening the counseling services, accompanying clients to higher health facilities to obtain LAPM services, and providing services for groups of clients. All village midwives emphasized the importance of strengthening collaboration among stakeholders to increase the uptake of LAPM services.

KEY CONCLUSIONS

as midwives are the main family planning providers in Indonesia, efforts to address their challenges is essential. Enabling a supportive policy environment, strengthening promotional activities, increasing the number of training programs designed for village midwives-in addition to enhancing inter-sectoral collaboration-are some recommendations to improve LAPM uptake in study areas.

Factors influencing use of family planning in women living in crisis affected areas of Sub-Saharan Africa: A review of the literature

BACKGROUND

far too many women continue to die from pregnancy and childbirth related causes. While rates have decreased in the past two decades, some areas of the world such as sub-Saharan Africa continue to have very high maternal mortality rates. One intervention that has been demonstrated to decrease maternal mortality is use of family planning and modern contraception, yet rates of use in sub-Saharan countries with the highest rates of maternal death remain very low.

AIM

to review available research and summarize the factors that inhibit or promote family planning and contraceptive use among refugee women and women from surrounding areas living in Sub-Saharan Africa.

DESIGN

a review of the literature.

DATA SOURCES

Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID, power search, and PubMed databases.

REVIEW METHODS

studies included were: (1) published in English from 2007 to present; (2) primary research; and (3) focused on family planning and contraceptive use among refugee women and women in surrounding areas. Findings were discussed within the framework of the Interaction Model of Client Health Behavior.

FINDINGS

twelve studies met the inclusion criteria. Utilization of modern contraceptive methods was low. Women were socially influenced to avoid the use of contraceptives by husbands and others in the community. Reasons were a lack of trust in western medicine and the desire to have large families. Low socioeconomic status and proximity of family planning clinics were barriers to access. Women believed that health care providers were unqualified, many described being treated with disrespect in the health clinics. Knowledge and understanding of contraceptives was low; while most women knew different methods were available, there were many misconceptions. Believing that certain contraceptives cause death, infertility and side effects, contributed to fear of use. This lack of knowledge and fear, even with the desire to space and limit births, affected motivation to use contraception.

CONCLUSIONS

developing new approaches to educating women, men (husbands), community leaders as well as healthcare providers is needed to address the multi-factorial issues that contribute to underuse of family planning services, thus contraceptive use.

IMPLICATIONS FOR PRACTICE

while lack of access to family planning is a barrier to use, interventions that improve access must be affordable and include education regarding contraceptive methods, preferably from those within the community. However, education and access is not sufficient unless the issue of disrespect by healthcare providers is addressed. Respectful and culturally sensitive care for all women, regardless of socio-economic status or country of origin, must be provided by midwives and other women health providers.

Evaluation of the Nigerian Urban Reproductive Health Initiative (NURHI) Program

Gaps remain in understanding whether family planning (FP) programs can change urban women's FP behaviors. Even less is known about what works among poor urban women. This article presents results of the impact evaluation of the Nigerian Urban Reproductive Health Initiative (NURHI). Findings are based on recently collected longitudinal data from women and facilities in six cities in Nigeria. Over the four-year follow-up period, there was an increase of about ten percentage points in modern method use. Impact evaluation analyses using fixed-effects regression methods indicate that both demand- and supply-side program activities increased modern method use. Radio, television, community events, and living near program-enrolled health facilities all significantly increased modern method use or were related to a desire for no more children among all women and among poor women. Results are discussed with an eye toward the design and scale-up of future family planning programs in urban Nigeria and elsewhere in sub-Saharan Africa.

Trends of contraception use among married reproductive age women: Tehran lipid and glucose cohort study 2002-2011

OBJECTIVES

This study aimed to examine the trends of contraception use among married reproductive age women in Tehran Lipid and Glucose study between 2002 and 2011.

METHODS

This analysis investigated a proportion of women users and non-users of family planning, using data from 10year population-based Tehran Lipid Glucose Study from surveys conducted in 2002, 2005, 2008, and 2011. Of the 6813, 6993, 7077, and 6789 women in the four phases mentioned, 34.1%, 33.9%, 33.5% and 35% of participants in each phase preferred to use contraception. Number of participants studied were 2506 women in 2002, 2529 women in 2005, 2594 women in 2008 and 2525 women in 2011.

RESULTS

Types of methods and patterns of change in contraception differed across time. The percentage of women using traditional methods increased significantly from 25.7% in 2002 to 34.6% in 2011 (p value for trend=0.001). Accordingly, modern contraception use showed a reverse trend. From 2002 to 2011, 61.4%, 61%, 57.7%, and 51% of married women reported currently using various modern contraceptives, respectively (p value for trend=0.001). The proportion of users relying on condoms showed a significant increase during this decade, being 10.9% in 2002, 15.2% in 2005, 20% in 2008 and 21.9% in 2011. The prevalence of non-users for contraception was generally low; 12.7%, 8.2%, 8% and 14.3%, respectively from 2002 to 2011, but increased significantly across time (p=0.005) CONCLUSION: Relying on less effective contraceptive methods has increased rapidly among women in the Tehran Lipid and Glucose cohort study, a trend that could be a warning to policy makers about the possibility of higher unsafe abortion and maternal mortality/morbidity rates in the near future.

DO THE SEX COMPOSITION OF LIVING CHILDREN AND THE DESIRE FOR ADDITIONAL CHILDREN AFFECT FUTURE INTENTION TO USE CONTRACEPTION IN ETHIOPIA?

Information on future intention to use contraceptives is a potential programme indicator for family planning services. Using three consecutive rounds of Ethiopian Demographic and Health Survey (EDHS) data collected in 2000, 2005 and 2011, this study examined whether the sex composition of living children and future desire for additional children were associated with the intention to use contraceptives among Ethiopian women aged 15-49 years who were not using any method of contraception at the time of the survey. The pooled multivariate binary logistic regression analysis indicated that between 2000 and 2011, the intentions of non-users to use contraceptives in the future increased significantly. Women who had at least one child (with an equal number of boys and girls, more boys than girls or more girls than boys) who did not want any more children, and those who were unsure about their desire for additional children, showed an increased intention to use contraceptives in the future, compared with those with an equal number of boys and girls who expressed a desire for additional children. Women with no children and who did not want children, or those who were unclear about their future desire, showed a lower intention to use contraceptives, compared with women with an equal number of boys and girls who wanted a child in the future.

Economic Evaluation of Family Planning Interventions in Low and Middle Income Countries; A Systematic Review

BACKGROUND

A significant number of women in low and middle income countries (L-MICs) who need any family planning, experience a lack in access to modern effective methods. This study was conducted to review potential cost effectiveness of scaling up family planning interventions in these regions from the published literatures and assess their implication for policy and future research.

STUDY DESIGN

A systematic review was performed in several electronic databases i.e Medline (Pubmed), Embase, Popline, The National Bureau of Economic Research (NBER), EBSCOHost, and The Cochrane Library. Articles reporting full economic evaluations of strategies to improve family planning interventions in one or more L-MICs, published between 1995 until 2015 were eligible for inclusion. Data was synthesized and analyzed using a narrative approach and the reporting quality of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

RESULTS

From 920 references screened, 9 studies were eligible for inclusion. Six references assessed cost effectiveness of improving family planning interventions in one or more L-MICs, while the rest assessed costs and consequences of integrating family planning and HIV services, concerning sub-Saharan Africa. Assembled evidence suggested that improving family planning interventions is cost effective in a variety of L-MICs as measured against accepted international cost effectiveness benchmarks. In areas with high HIV prevalence, integrating family planning and HIV services can be efficient and cost effective; however the evidence is only supported by a very limited number of studies. The major drivers of cost effectiveness were cost of increasing coverage, effectiveness of the interventions and country-specific factors.

CONCLUSION

Improving family planning interventions in low and middle income countries appears to be cost-effective. Additional economic evaluation studies with improved reporting quality are necessary to generate further evidence on costs, cost-effectiveness, and affordability, and to support increased funding and investments in family planning programs.

Community-Based Financing of Family Planning in Developing Countries: A Systematic Review

In this systematic review, we gather evidence on community financing schemes and insurance programs for family planning in developing countries, and we assess the impact of these programs on primary outcomes related to contraceptive use. To identify and evaluate the research findings, we adopt a four‐stage review process that employs a weight‐of‐evidence and risk‐of‐bias analytic approach. Out of 19,138 references that were identified, only four studies were included in our final analysis, and only one study was determined to be of high quality. In the four studies, the evidence on the impact of community‐based financing on family planning and fertility outcomes is inconclusive. These limited and mixed findings suggest that either: 1) more high‐quality evidence on community‐based financing for family planning is needed before any conclusions can be made; or 2) community‐based financing for family planning may, in fact, have little or no effect on family planning outcomes.

Towards comprehensive early abortion service delivery in high income countries: insights for improving universal access to abortion in Australia

BACKGROUND

Improving access to safe abortion is an essential strategy in the provision of universal access to reproductive health care. Australians are largely supportive of the provision of abortion and its decriminalization. However, the lack of data and the complex legal and service delivery situation impacts upon access for women seeking an early termination of pregnancy. There are no systematic reviews from a health services perspective to help direct health planners and policy makers to improve access comprehensive medical and early surgical abortion in high income countries. This review therefore aims to identify quality studies of abortion services to provide insight into how access to services can be improved in Australia.

METHODS

We undertook a structured search of six bibliographic databases and hand-searching to ascertain peer reviewed primary research in English between 2005 and 2015. Qualitative and quantitative study designs were deemed suitable for inclusion. A deductive content analysis methodology was employed to analyse selected manuscripts based upon a framework we developed to examine access to early abortion services.

RESULTS

This review identified the dimensions of access to surgical and medical abortion at clinic or hospital-outpatient based abortion services, as well as new service delivery approaches utilising a remote telemedicine approach. A range of factors, mostly from studies in the United Kingdom and United States of America were found to facilitate improved access to abortion, in particular, flexible service delivery approaches that provide women with cost effective options and technology based services. Standards, recommendations and targets were also identified that provided services and providers with guidance regarding the quality of abortion care.

CONCLUSIONS

Key insights for service delivery in Australia include the: establishment of standards, provision of choice of procedure, improved provider education and training and the expansion of telemedicine for medical abortion. However, to implement such directives leadership is required from Australian medical, nursing, midwifery and pharmacy practitioners, academic faculties and their associated professional associations. In addition, political will is needed to nationally decriminalise abortion and ensure dedicated public provision that is based on comprehensive models tailored for all populations.

"A Baby Was an Added Burden": Predictors and Consequences of Unintended Pregnancies for Female Sex Workers in Mombasa, Kenya: A Mixed-Methods Study

INTRODUCTION

Female sex workers (FSW) have high rates of unintended pregnancy, sexually transmitted infections including HIV, and other adverse sexual and reproductive health outcomes. Few services for FSWs include contraception. This mixed-methods study aimed to determine the rate, predictors and consequences of unintended pregnancy among FSWs in Mombasa, Kenya.

METHODS

A prospective cohort study of non-pregnant FSWs was conducted. Quantitative data were collected quarterly, including a structured questionnaire and testing for pregnancy and HIV. Predictors of unintended pregnancy were investigated using multivariate logistic regression. Qualitative data were gathered through focus group discussions and in-depth interviews with FSWs who became pregnant during the study, and interviews with five key informants. These data were transcribed, translated and analysed thematically.

RESULTS

Four hundred women were enrolled, with 92% remaining in the cohort after one year. Fifty-seven percent reported using a modern contraceptive method (including condoms when used consistently). Over one-third (36%) of women were using condoms inconsistently without another method. Twenty-four percent had an unintended pregnancy during the study. Younger age, having an emotional partner and using traditional or no contraception, or condoms only, were independent predictors of unintended pregnancy. Women attributed pregnancy to forgetting to use contraception and being pressured not to by clients and emotional partners, as well as "bad luck". They described numerous negative consequences of unintended pregnancy.

CONCLUSION

Modern contraceptive uptake is surprisingly low in this at-risk population, which in turn has a high rate of unintended pregnancy. The latter may result in financial hardship, social stigma, risk of abandonment, or dangerous abortion practices. FSWs face considerable barriers to the adoption of dual method contraceptive use, including low levels of control in their emotional and commercial relationships. Reproductive health services need to be incorporated into programs for sexually transmitted infections and HIV, which address the socially-determined barriers to contraceptive use.