Family planning: the unfinished agenda

Urban Family Planning in Low- and Middle-Income Countries: A Critical Scoping Review

Health agendas for low- and middle-income countries (LMICs) should embrace and afford greater priority to urban family planning to help achieve a number of the global Sustainable Development Goals. The urgency of doing so is heightened by emerging evidence of urban fertility stalls and reversals in some sub-Saharan African contexts as well as the significance of natural increase over migration in driving rapid urban growth. Moreover, there is new evidence from evaluations of large programmatic interventions focused on urban family planning that suggest ways to inform future programmes and policies that are adapted to local contexts. We present the key dimensions and challenges of urban growth in LMICs, offer a critical scoping review of recent research findings on urban family planning and fertility dynamics, and highlight priorities for future research.

Effects of rotating at a Catholic hospital on medical student contraceptive objective structured clinical exam scores

OBJECTIVES

To assess the impact of rotating at a Catholic vs non-religious institution for the inpatient portion of the third-year medical school obstetrics and gynecology clerkship on medical students' contraceptive competency.

STUDY DESIGN

We assigned all medical students completing an obstetrics and gynecology clerkship during the 2017-2019 academic years to a Catholic or non-religious hospital for their inpatient teaching site, where they gain much of their contraceptive counseling experience. All students attended the same didactic sessions on contraception. We compared Objective Structured Clinical Exam (OSCE) scores and clerkship grades between the two clinical sites for all medical students. We set significance at p < 0.05.

RESULTS

Of 281 medical students, the 127 (45.2%) who had rotated at a Catholic hospital performed lower on the data-gathering component of the contraceptive OSCE compared with students at the non-religious hospitals (Catholic: 62.4 ± 16.5 vs non-religious: 70.2 ± 15.9, p < 0.01) and had lower total contraceptive OSCE scores (Catholic: 69.4 ± 9.3 vs non-religious: 72.0 ± 8.5, p < 0.01). Clinical reasoning and communication scores for the contraceptive OSCE, data-gathering and total scores for other OSCE scenarios, overall OSCE and clerkship grades were not different.

CONCLUSION

Rotation at a Catholic hospital, with fewer opportunities for medical students to experience contraceptive counseling, was associated with poorer data-gathering skills for gynecologic and sexual history. While contraceptive knowledge can be imparted didactically, hands-on history-taking and counseling experiences are needed to build competency in contraceptive care.

IMPLICATIONS

There is a disparity in medical student family planning training at a Catholic hospital compared with non-religious hospitals. Contraceptive knowledge can be attained through didactic sessions, however additional hands-on practice is needed in gynecologic and sexual history taking if clinical opportunities are limited.

Use of modern contraceptives in Lagos Nigeria during the COVID-19 pandemic

We estimated modern contraceptive prevalence rate (mCPR) and examined predictors of modern contraceptives utilization amongst 1,445 sampled reproductive age women in Lagos (Nigeria's epicenter) during the devastating COVID-19 pandemic. Estimated mCPR was 30.8%. Women aged 20-29 years were 50% (95%CI:0.37-0.71) less likely to use modern contraceptives during the pandemic than those 30-39 years. Married and divorced women were about three (95%CI:1.37-5.25) and over three (95%CI:1.32-7.79) times more likely to use modern contraceptives compared to single women. Though mCPR has not reduced, sustained contraceptive needs assessment of sometimes obscure sub-populations is required, especially if outbreaks like COVID-19 become our 'new normal'.

Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Analysis of Myanmar Demographic and Health Survey (2015-2016)

Reproductive health service is crucial for youth to reduce maternal and child mortality. However, many young women face unintended pregnancies and pregnancy-related complications due to insufficient knowledge of contraceptive methods and low contraceptive utilization. This study aims to assess the modern contraceptive prevalence rates among youth and identify factors influencing modern contraceptive utilization among youth. We used Myanmar Demographic and Health Survey (2015-2016) data. This study included 1,423 men and 3,677 women aged 15-24 years from all states and regions of Myanmar. We used multivariable binary logistic regression analysis and reported the results using adjusted Odds Ratios (AOR) with 95% Confidence Intervals (CI). Data analysis was done by STATA software (version 15.1). Ever-married youth used mainly injectable contraception, followed by oral contraceptive pills. Never-married male youth mainly used oral contraceptive pills; however, almost all never-married female youth did not use contraception. The modern contraceptive prevalence rates were 14.9% among total youth, 10% among males, 16.8% among females, 1.5% among never-married males, 44.7% among ever-married males, and 54% among ever-married female youth. The knowledge on modern contraceptive methods favored the utilization. Sexually active youth utilized more contraception than sexually inactive youth. We also found geographical variation and low utilization among rural youth. The desire for more children was also a significant predictor of contraceptive utilization among married youth. The utilization of modern contraception was low among Myanmar youth. Reproductive health program needs to be emphasized on the youth population especially in the area with low utilization to have equitable access to quality reproductive health services. Moreover, the revitalization of Youth Information Corner and youth-friendly reproductive health education programs should be implemented to increase reproductive health knowledge and prevent unsafe sex, unintended pregnancies, and abortions which might help in reducing maternal and child mortality. We warranted conducting mixed method studies to explore the barriers and challenges of contraceptive utilization and male involvement in the choice of contraception among youth.

The role of structural and process quality of family planning Care in Modern Contraceptive use in Indonesia: a multilevel analysis

Introduction

Despite contraceptive behaviors are influenced by multiple and multilevel variables, studies on modern contraceptive use in Indonesia has concentrated on single-level and mostly individual and household variables, and less interest has been devoted to multilevel analysis that accounts for community and SDP characteristics that may affect woman’s decision to use modern FP method. This study aimed to assess the role of structural and process quality of family planning care in modern contraceptive use among women in reproductive ages in Indonesia.

Methods

This study analyzed data from the 2016 PMA2020 survey of 10,210 women in 372 enumeration areas in Indonesia. The data were analyzed using categorical principal component analysis and multilevel mixed-effects logistic regression.

Results

The key variables for structural quality were number of contraceptive provided, SDP supports CHWs, available water and electricity, and skilled FP personnel, while the main factors for process quality were privacy of clients and provision of post-abortion service. There were significant differences across communities in how study variables associated with modern FP adoption. The finding shows the evidence of significant roles of structural and process quality FP care in modern contraceptive use. Moreover, women with high autonomy in FP decision, those who had free national/district health insurance, and those living in a community with higher proportion of women visited by CHW, had higher odds of modern contraceptive usage. Yet, women who live in a community with higher mean ideal number of children or greater proportion of women citing personal/husband/religion opposition to FP, had lower odds of modern contraceptive use than their counterparts.

Conclusion

Study findings suggest improvement in structural and process quality of FP care will yield substantial growths in modern contraceptive use. Moreover, FP workers should also address adverse cultural/traditional customs in community and should target communities where the demand for modern FP was degraded by opposing social beliefs and norms. There was significant variation across communities in how individual, household, community, and SDP factors affect modern FP practice, hence, context should be taken into consideration in the development of FP intervention and promotion programs.

The Impact of Mass Media-Delivered Family Planning Campaigns in Low- and Middle-Income Countries: A Meta-Analysis of Advertising and Entertainment-Education Format Effects

Effective family planning methods are shown to save lives, contribute to gender equality, and boost economic development. Mass media communication campaigns in low- and middle-income countries have been effective in increasing contraceptive use, although the strategies that increase the likelihood of success are unclear. The present study uses meta-analyses to uncover the average effect of media campaigns on family planning behaviors in low- and middle-income countries and to examine the effectiveness of two communication strategies: entertainment-education and advertising/public service announcements. Results indicated that mass media-delivered family planning campaigns have a positive impact on family planning behaviors: d = 0.19, 95% CI [0.15, 0.24] for women (k = 64), d = 0.16, 95% CI [0.11, 0.21] for men (k = 27), and d = 0.20, 95% CI [0.17, 0.23] for an undifferentiated target group of men and women (k = 37). The use of an entertainment-education format, often in addition to campaign advertising messages, was associated with greater campaign success rates for women. Men, however, responded negatively to education-entertainment and positively to campaigns using only advertising and public service announcement formats. Recommendations for future family planning mass media campaigns and academic research opportunities are discussed.

The family planning "know-do" gap among married women of reproductive age in urban Pakistan

OBJECTIVE

To examine the prevalence and predictors of family planning (FP) know-do gaps among married women of reproductive age (MWRA) in low socio-economic urban areas of Karachi, Pakistan.

DESIGN

This was a cross-sectional survey of randomly selected 7288 MWRA (16-49 years) to identify predictors of the know-do gap in FP using a logistic regression model.

RESULTS

More than one third (35.5%) of MWRA had FP know-do gap, i.e., despite having a knowledge of contraceptives and desire to limit or delay childbearing, they were not using contraceptives. Women were less likely to use FP if they were getting older (25-35 years: OR 1.45, 95% CI 1.09-1.94; >35 years: OR 3.02, 95% CI 1.90-4.80), from certain ethnicities (Sindhi: OR 1.64, 95% CI 1.11-2.42; Saraiki: OR 1.66, 95% CI 1.01-2.71; other minorities: OR 2.37, 95% CI 1.63-3.44); did not receive FP counselling: OR 1.43, 95% CI 1.13-1.80; and had not made a joint decision on FP: OR 1.44, 95% CI 1.06-1.98). Conversely, women were more likely to use contraceptives if they had >10 years of schooling (OR 0.66, 95% CI 0.46-0.94), with each increasing number of a living child (OR 0.68, 95% CI 0.62-0.75) and each increasing number of contraceptive method known (OR 0.93, 95% CI 0.88-0.98).

CONCLUSION

The predictors associated with the FP know-do gap among MWRA should be considered when planning future strategies to improve the contraceptive prevalence rate in Pakistan.

Association between socioeconomic status and fertility among adolescents aged 15 to 19: an analysis of the 2013/2014 Zambia Demographic Health Survey (ZDHS)

Background

Adolescents face significant barriers to access and utilization of sexual and reproductive health services in many low-income settings, which in turn may be associated with adverse consequences such as early pregnancy, sexually transmitted infections, unsafe abortion and mortality. There is evidence suggesting that limited access to sexual and reproductive health information and services among adolescents contributes to these outcomes. We aimed to find out the factors that affect the fertility of adolescents aged 15 to 19 years in Zambia and to identify possible drivers of adolescents’ fertility.

Methods

Secondary analysis of the ZDHS 2013/14 data was carried out to find out the factors that affect the fertility rate of adolescents aged 15 to 19 years using multivariate logistic regression (n = 3666).

Results

Overall, 23.1% of adolescents had given birth at least once in the 5 years leading to the survey (n = 3666, 99.4% response), and 49.8% were rural-based while 50.2% were urban-based. The median number of schooling was 8 years (IQR 6–10). About 52% of the adolescents were in the poorer, poor and medium wealth quintiles while the other 48% were in the rich and richer quintiles. Factors found to affect fertility include residence, wealth status, educational attainment, marriage and abortion. An urban-based adolescent with a lower socioeconomic status was 2.4 times more likely to give birth compared to rural-based poorer adolescents (aOR = 2.4, 95% CI: 1.5, 3.7, p < 0.001). Although odds of giving birth were much higher among rural-based married adolescents (aOR = 8.0, 95% CI: 5.4, 11.9, p < 0.001) compared to urban married adolescents (aOR = 5.5, 95% CI: 8.3, 16.0, p < 0.001), and these relationships both statistically significant, higher educational attainment (aOR = 0.7, 95% CI: 0.6, 0.8 p < 0.001) and abortion (aOR = 0.3, 95% CI: 0.1, 0.8, p = 0.020) reduced these odds, particularly for rural-based adolescents.

Conclusion

Despite response aimed at reducing adolescent fertility, low wealth status, low educational attainment and early marriage remain significant drivers of adolescent fertility in Zambia. There is a need to address sexual and reproductive health needs of urban-based adolescents with a lower socioeconomic status.

Adolescents go through serious challenges related to accessing and using sexual and reproductive health services in many low-income settings, and may also be related to negative consequences such as early pregnancy, sexually transmitted infections and unsafe abortion and death. Research has revealed that limited access to sexual and reproductive health information and services among young people contributes to these negative consequences. This analysis aimed to find out the factors that affect the fertility of 3666 adolescents aged 15 to 19 years in Zambia and to identify possible drivers of adolescents’ fertility, using the Zambia Demographic and Health Survey conducted in 2013/2014. A little over a quarter of the adolescents had given birth at least once in the five years leading to the survey. About half of the young people were rural-basedwhile the other half were urban-based, with an average of about 8 years in school. The rural-based adolescents had slightly lower average years in school compared to the urban-based; 7 years and 9 years respectively. Living in a rural area, residing in a home with a low wealth status and being married were all linked to higher chances of giving birth, while terminating a pregnancy and having more years of education were linked to lower chances of giving birth among the adolescents. Urban-based adolescents with lower wealth status were also linked to higher chances of giving birth compared to urban-based adolescents with higher wealth status. These results suggest that while residing in rural areas and being married increase the chances of higher fertility, the adolescents in urban areas but with lower wealth status also need interventions aimed at reducing their fertility.

Heterogeneity of Modern Contraceptive Use among Urban Slum and Nonslum Women in Kinshasa, DR Congo: Cross-Sectional Analysis

Urban populations have been increasing at an alarming rate, with faster growth in urban slums than that in nonslums over the past few decades. We examine the association between slum residence and the prevalence of contraceptive use among women of reproductive age, and assess if the effect was modified by household wealth. We conducted cross-sectional analysis comprising 1932 women in slums and 632 women in nonslums. We analyzed the moderating effect through an interaction between household wealth and neighborhood type, and then conducted stratified multivariable logistic-regression analysis by the type of neighborhood. Fewer women living in nonslum neighborhoods used modern methods compared to those living in slum neighborhoods. Within slum neighborhoods, the odds of using modern contraceptive methods were higher among women visited by community health workers than among those who had not been visited. Parity was one of the strong predictors of modern contraceptive use. Within nonslum neighborhoods, women from the wealthiest households were more likely to use modern contraceptives than those from the poorest households. Household wealth moderated the association between the type of neighborhood and modern contraceptive use. The study findings suggested heterogeneity in modern contraceptive use in Kinshasa, with a surprisingly higher contraceptive prevalence in slums.

Competency Assessment of Project Managers of a National NGO in India

Public health projects carried out by non-government organisations (NGOs) are considered a critical contributor in the provision of health services to rural population in India. But there is clear lack of documented evidence that describes the capacity and competency of the NGO project managers to successfully design and implement a new project. This article presents findings of an exploratory case study using outreach model of family planning service delivery as an example to understand the steps and actions taken by senior managers throughout the project’s life cycle and competencies required by them to execute the project. Focus group discussion followed by paper-based survey using sections of Management Competency Assessment Tool was conducted with senior managers of the chosen NGO. The results indicate that the strategies developed by the NGO managers are consistent with the existing literature on project management. However, not all managers have the same level of confidence in demonstrating the competencies of (a) knowledge of healthcare environment; (b) evidence informed decision making; and (c) interpersonal, communication qualities and relationship management. The organisation needs to invest in human resource development using mixed approach of providing training, team building activities, mentoring, and support.

Family Welfare Expenditure, Contraceptive Use, Sources and Method-Mix in India

Making universal access to sexual and reproductive health care a reality, and thus building momentum for comprehensive family planning by 2030, is key for achieving sustainable development goals. However, in the last decade, India has been retreating from progress achieved in access to family planning. Family planning progress for a large country such as India is critical for achieving sustainable developmental goals. Against this backdrop, the paper investigated the question of how far family welfare expenditure affects contraceptive use, sources of contraceptive methods, and method-mix using triangulation of micro and macro data analyses. Our findings suggest that, except for female sterilizations, modern methods of contraception do not show a positive relationship with family welfare expenditure. Notwithstanding a rise in overall family welfare expenditure, spending on core family planning programs stagnates. State-wise and socio-economic heterogeneity in source-mix and method-mix continued to influence contraceptive access in India. Method-mix continued to skew towards female sterilization. Public sector access is helpful only for promoting female sterilization. Thus, the source-mix for modern contraceptives presents a clear public-private divide. Over time, access to all contraceptive methods by public sources declined while the private sector has failed to fill the gap. In conclusion, this study identified a need for revitalizing family planning programs to promote spacing methods in relatively lower-performing states and socio-economic groups to increase overall contraceptive access and use in India through the rise in core family planning expenditure.

Quality of Care in Family Planning Services: Differences Between Formal and Informal Settlements of Kira Municipality, Uganda

Background: Quality of care (QoC) of family planning (FP) affects contraceptive use, and it varies across types of urban settlement. This study assesses the difference in service delivery point (SDP) structural and process factors between formal and informal urban settlements, and the opinion of the client on the QoC in informal settlements. This is useful in creating an evidence base to advocate for better quality services for the most vulnerable in society. Methods: This was a cross-sectional survey that included SDPs of Kira municipality in Wakiso district, Uganda. Data were collected from all the service points in Kira municipality with the caretakers consented. In addition, using multi-stage sampling, 626 women of reproductive age (15-49 years) who lived in the informal settlements of Kira municipality were interviewed. Data were collected using structured questionnaires, descriptive analysis was carried out in Stata version 14.0, and Chi-square and t-tests were used to compare the informal with the formal settlements. Results: Formal settlements generally had more higher-level SDPs compared to informal settlements (value of p < 0.001). SDPs in the formal settlements provided more FP methods and had more community health workers (CHW) to support their work. Also, SDPs in the formal settlements were more likely to have long-term FP methods available and more likely to have trained personnel to insert and remove implants and IUDs compared to those in informal settlements. Additionally, more SDPs in the formal settlements provided counseling for permanent, long-term, and short-term FP methods. Of the 626 interviewed women, most of the women (68.6%) reported that they would not return to the previous FP provider or refer a friend to the same provider (72.7%). Conclusions: There is a lower quality FP services in the informal settlements with a commensurable effect on the client satisfaction with the services. Therefore, improving the quality of FP services in informal settlements should be a top priority. Improved quality of services could act as a motivation to increase the uptake of modern contraceptives in such settings.

Family planning in Pacific Island Countries and Territories (PICTs): A scoping review

The use of contraceptives for family planning improves women's lives and may prevent maternal deaths. However, many women in low and middle-income countries, including the Pacific region, still die from pregnancy-related complications. While most health centres offer family planning services with some basic contraceptive methods, many people do not access these services. More than 60% of women who would like to avoid or delay their pregnancies are unable to do so. This scoping review identifies and analyses evidence about family planning service provision in Pacific Island Countries and Territories (PICTs), with the aim of better informing family planning services for improved maternal health outcomes in the Pacific. We used Arksey and O'Malley's scoping review guidelines, supported by Levac, Colquhoun and O'Brien to identify gaps in family planning service provision. Selected studies included peer-reviewed publications and grey literature that provided information about family planning services from 1994 to 2019. Publication data was charted in MS Excel. Data were thematically analysed and key issues and themes identified. A total of 45 papers (15 peer-reviewed and 30 grey literature publications) were critically reviewed. Five themes were identified: i) family planning services in the Pacific; ii) education, knowledge and attitudes; iii) geographical isolation and access; iv) socio-cultural beliefs, practices and influences; and v) potential enabling factors for improved family planning, such as appropriate family planning awareness by health care providers and services tailored to meet individual needs. While culture and religion were considered as the main barriers to accessing family planning services, evidence showed health services were also responsible for limiting access. Family planning services do not reach everyone. Making relevant and sustainable improvements in service delivery requires generation of local evidence. Further research is needed to understand availability, accessibility and acceptability of current family planning services for different age groups, genders, social and marital status to better inform family planning services in the Pacific.

The road from ICPD to SDGs: Health returns of reducing the unmet need for family planning in India

OBJECTIVE

This study attempts to estimate the impact of reducing the unmet need for family planning on the key maternal and child health indicators in India from 1993 to 2016, and projecting this for the period from 2016 to 2030.

DATA AND METHODS

The data have been compiled from various sources such as the United Nations' World Population prospects, national family health surveys and the sample registration system. The family planning and demographic projection modules of 'Spectrum', a modular computer simulation program, were used to estimate the impact of family planning programmes on reproductive, maternal and child health outcomes in India from 1993 to 2030.

RESULTS

Reduction of the unmet need for family planning averted approximately 56 million unintended pregnancies, 7 million unsafe abortions and 167,000 maternal deaths between 1993 and 2016. It is expected that an additional 41 million unintended pregnancies, 5 million unsafe abortions and 124,000 maternal deaths can be avoided by reducing the unmet need for family planning to 5% by 2030. Similarly, the declining unmet need for family planning between 1993 and 2016 led to a reduction in the pregnancy rate, abortion rate, and risk-adjusted infant and under-five mortality rates by 27 per 1000 married women, 1.8 per million married women, 10 per 1000 live births and 15 per 1000 live births, respectively. It is expected that approximately 24 pregnancies per 1000 married women, 1.6 abortions per million married women, 10 risk adjusted infant deaths per 1000 live births, and 14 under-five deaths per 1000 live births can be avoided by reducing the unmet need for family planning to 5% by 2030.

CONCLUSIONS

The findings of this study advocate that family planning is one of the best return on-investment strategies for India to achieve several targets under the reproductive, maternal and child health-related sustainable development goals.

Prevalence and Predictors of Contraceptive Use Among Women of Premenopausal Period in Ethiopia: A Retrospective Cross-Sectional Data Analysis

Background

Contraceptive use is internationally endorsed as a human right and an indicator of the highest standard of sexual and reproductive health life. But reports from countries including Ethiopia showed a lower and capricious rate due to wider factors. Thus, the current study aimed to determine the prevalence and the predictors of contraceptive use among women of the premenopausal period.

Methods

A retrospective cross-sectional data analysis was performed from Ethiopian Demographic and Health survey 2019 in January 2021. A total of 3260 premenopausal women were included by stratified sampling, and data were analyzed using SPSS version 25 software. Data were initially analyzed descriptively, and tests were done for variable multicollinearity, and model goodness of fit and predictive capacity. Subsequently, bivariate and multivariable logistic regression analyses were performed successively for the crude and adjusted odds ratio, and finally declared variables with a p-value of <0.05 as predictors of contraceptive use.

Results

The study included 3260 women with an average age of 41.66 (standard deviation ±3.9) years. The overall prevalence of contraceptive use was reported 17% and explained to vary by women’s age, place of residence, education level, wealth index, and current working statuses. However, only the age, education, and wealth index of women have predicted a statistical significance with contraceptive use. Accordingly, an increase in women’s age was found to increase contraceptive use more likely by 89% [AOR=0.89 (95% CI: 0.87, 0.92)]. Similarly, primary [AOR = 1.53, (95% CI: 1.20, 195)], secondary [AOR = 2.57, (95% CI: 1.70)] or higher [AOR = 2.64, (95% CI: 1.67, 4.20)] level educated women were about twice more likely to use contraceptive methods than uneducated women. Finally, women in poorer [AOR = 3.11 (95% CI: 2.17, 4.46)], middle [AOR = 3.03 (95% CI: 2.09, 4, 37)], rich [AOR = 3.70, (95% CI: 2.58, 5.31)] or richest [AOR = 3.42, (95% CI: 2.39, 4, 88)] wealth index were more than 3 times more likely use contraceptive methods when compared to women of the poorest wealth index.

Conclusion

The prevalence of contraceptive use among premenopausal women in Ethiopia is low and utmost related to age, education level, and wealth index of women.

Demographic and socio-cultural factors influencing contraceptive uptake among women of reproductive age in Tamale Metropolis, Northern Region, Ghana

Background

This study assessed some demographic and socio-cultural factors that influence contraceptive uptake among reproductive-aged women in Tamale Metropolis of the Northern Region, Ghana.

Design

This was a cross-sectional study conducted from February to March 2015.

Setting

All three sub Metropolis in Tamale.

Participants

All community members and women of reproductive age (15-49 years).

Intervention

The study used cluster sampling to recruit women who were interviewed using a structured questionnaire. Nine focus group discussions (FGDs) were also held among community members who were purposively selected.

Main outcome measures

contraceptive uptake (use of contraceptive).

Results

The mean age of the women was 26 years. The prevalence of contraceptive uptake among reproductive-age women was 36.8% (165/448). Women with secondary school education [AOR=4.4(95%CI:1.6-12.4)], and those in homes where decisions on having children were made by both partners [AOR=2.1(95%CI:1.1-04.42)] were more likely to use contraceptives. Unemployed women [AOR=0.3(95%CI:0.1-0.8)], women whose husbands were unaware of their contraceptive use [AOR=0.4(95%CI:0.2-0.9)] and those having a culture or religion that frowns on contraceptive use [AOR=0.4(95%CI:0.2-0.8)] were less likely to use contraceptive among women in the Tamale Metropolis.

Conclusion

The study found a contraceptive prevalence rate (CPR) in Tamale Metropolis, Northern Ghana to be 36.8%. Education and living in a home where childbearing decisions are made together were identified as positive factors influencing contraceptive uptake.

Funding

This work was funded by the authors.

Patterns and determinants of modern contraceptive use and intention to usecontraceptives among Malawian women of reproductive ages (15-49 years)

BACKGROUND

Malawi is one of the countries in SSA with the highest TFR. This study aimed to explore factors associated with modern contraceptive use and intention to use contraceptives among women of reproductive ages (15-49 years) in Malawi.

METHODS

The study used secondary data from 2015 to 16 Malawi Demographic and Health Survey (MDHS) dataset. Logistic regression models were used to derive adjusted odd ratios as the measures of association between need, predisposing and enabling factors, and contraceptive use and the intention to use contraceptives among women. The sample constituted 24,562 women who were successfully interviewed during the MDHS. All comparisons are considered statistically significant at 5% level.

RESULTS

Overall 54.8% of women were currently using contraceptives, while 69.1% had the intention to use contraceptives. The odds of contraceptive use were significantly low among, women aged 15-19 years, 20-24 years, 25-29 years, 30-34 years, 35-39 years and 40-44 years compared to women aged 45-49 years; women of Tonga ethnic group (OR = O.60, CI = 0.43 0.84) compared to women of Nyanga ethnic group; women from poor households (OR = 0.78, CI = 0.68-0.90) and middle income households (OR = 0.84, CI = 0.74-0.95) compared to women from rich household. Nonetheless, women with no past experience of terminated pregnancy (OR = 1.50, CI = 1.34-1.68) were more likely to use contraceptives compared to women with past experience of terminated pregnancy. Similarly, Women with primary education (OR = 1.56, CI = 1.16-2.09) and secondary education (OR = 1.39, CI = 1.04-1.85) were more likely to use contraceptives compared to women with higher education. While the odds of intending to use contraceptives were significantly high with age only thus among women aged 15-19 years, (OR = 15.18, CI = 5.94-38.77); 20-24 years (OR = 16.77, CI = 7.46-37.71); 25-29 years (OR = 6.75, CI = 3.16-14.45); 30-34 years (OR = 7.75, CI = 3.61-16.65) and 35-39 years (OR = 5.05, CI = 2.29-11.12) compared to women aged 45-49 years.

CONCLUSION

As direct policy measure; information, education and communication programmes on family planning among poor and middle income women, and all women in reproductive ages should be strengthened.

Provider perspectives in implementing the Postpartum Intrauterine Device Initiative in Sri Lanka: a qualitative study

BACKGROUND

Integration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery.

METHODS

We applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Findings indicated that providers were willing to adopt the intervention and reiterated the importance of postpartum family planning. However, the intervention was not consistently implemented as intended, including provider bias in counselling and lack of attention to women's preferences. Organisational barriers to implementation included time constraints and inadequate training. Providers suggested that a range of paramedical staff be trained in counselling and PPIUD insertion to mitigate barriers and to facilitate scaling up the intervention.

CONCLUSIONS

To improve and scale up the PPIUD Initiative, training efforts should be expanded to primary and secondary care facilities and implementation strategies better utilised (eg, on-the-job training). The training can be strengthened by improving providers' knowledge of all types of methods and interpersonal communication skills, and emphasising the importance of unbiased, evidence-based contraceptive counselling techniques.

Postpartum women's knowledge and planned use of contraception in Myanmar

BACKGROUND

Maternal mortality in Myanmar is one of the highest in the WHO South-East Asian region. Additionally, the country has a high unmet need for contraception and low rates of uptake of long-acting reversible contraceptive methods (LARCs) including intrauterine devices (IUDs) and implants. Engagement with health professionals around the time of a birth is an ideal opportunity for women to access contraception but immediate postpartum provision is not widely offered in Myanmar.

METHODS

We undertook a cross-sectional survey of women immediately postpartum at two hospitals in Yangon to investigate their knowledge, and past use of, contraceptive methods and their plans for postpartum contraception including perceptions of implants and IUDs. Four trained obstetrics staff collected data using electronic tablets between January 2017 and January 2018.

RESULTS

Of the 1755 participants, 55.1% had used pills and 42.2% injectables. In contrast, only 0.5% had used an IUD and 0.3% an implant. Few women (4.4%) anticipated starting contraception immediately postpartum and only a minority would consider future use of an implant (36.9%) or an IUD (13.0%). Fear of side effects was the major barrier to future implant and IUD uptake, reported by 64.5% and 62.5%, respectively.

CONCLUSIONS

Women in maternity care in Yangon have some awareness of IUDs and implants but many hold misconceptions about their side effects leading to reluctance to use. Reducing the unmet need for contraception and improving maternal outcomes in Myanmar could be achieved by improving education, policy and practice around immediate postpartum contraception provision, with a particular focus on LARC methods.

How the internet increases modern contraception uptake: evidence from eight sub-Saharan African countries

Background

Sub-Saharan African (SSA) countries have the highest worldwide levels of unmet need for modern contraception. This has led to persistently high fertility rates in the region, rates which have had major adverse repercussions on the development potential there. Family planning programmes play a key role in improving the uptake of modern contraception, both by fostering women’s health and by lowering their fertility. Increasing awareness of contraception benefits is a major component of such programmes. Here, we ask whether internet access can bridge the gap between women’s need for modern contraception and women’s uptake of the same.

Methods

We use a compendium of data for 125 242 women, aged 15–49, from the Demographic Health Survey, Akamai and International Communication Union data, covering eight SSA countries, for the period 2014–2019. We apply a Two-Stage Least Square model, using as instruments for individual internet exposure the distance to the main server in the country and whether the backbone network in the country has been connected to at least one submarine cable.

Results

Internet exposure, measured as women access the internet at least monthly (almost daily), is associated with a positive, 11.4% (95% CI 10.6% to 12.2%) (53.8% (95% CI 13.4% to 94.1%)), increase in modern contraception uptake. Education is an important moderator. Poorly educated women benefit the most from internet exposure.

Discussion

Internet exposure appears to have significantly increased the uptake of modern contraception among sub-Saharan women. The poorly educated appear particularly to benefit. There are two mechanisms at play: the internet increases women’s knowledge of contraception; and, in parallel, fosters their empowerment.

Barriers and Facilitators of Family Planning Use in Fishing Communities of Lake Victoria in Uganda

Introduction: Family planning (FP) is a key element in the conduct of research and is essential in managing family sizes. Although fishing communities (FCs) are targeted populations for HIV prevention research, their FP practices are poorly understood. We explored barriers and facilitators of FP use in FCs of Lake Victoria in Uganda. Methods: We employed a mixed-methods approach comprising a cross-sectional survey, in-depth interviews, and focus group discussions in 2 FCs. Multivariable logistic regression was used to analyze quantitative data and a thematic approach to generate themes from the qualitative data. Results: Up to 1410 individuals participated in the survey and 47 in the qualitative study. Just over a third (35.6%) used FP. The most commonly used methods were condoms, pills, and injectables. In Kigungu community, participants whose religion was Anglican and Muslim were more likely to use FP than Catholics (adjusted odds ratio [aOR] 1.45; 95% CI 1.05-1.99 and aOR 1.45; 95% CI 1.05-2.07, respectively). Participants were more likely to use FP if they had satisfactory FP knowledge compared to those with no satisfactory FP knowledge (aOR 1.79; 95% CI 1.23-2.61), or if they were married compared to their single counterparts (aOR 1.84; 95% CI 1.32-2.57). In both communities, participants were more likely to use FP if they had 2 or more sexual partners in the past 12 months than those with less than 2 sexual partners (aOR 1.41 95% CI 1.07-1.87 and aOR 2.60; 95% CI 1.36-4.97). Excessive bleeding and delayed fecundity; fertility desire; gender preferences of children; method stock outs and lack of FP trained personnel constituted barriers to FP use. There were also cultural influences in favor of large families. Conclusion: FP use in FCs is suboptimal. Barriers of FP use were mainly biomedical, religious, social, and cultural, which underscores a need for FP education and strengthening of FP service provision in FCs.

Structured and sustained family planning support facilitates effective use of postpartum contraception amongst women living with HIV in South Western Uganda: A randomized controlled trial

BACKGROUND

Despite low pregnancy intentions, many women accessing contraception discontinue use, increasing the risk of unwanted pregnancies among women living with HIV (WLWH). We evaluate whether a family planning support intervention, inclusive of structured immediate one-on-one postpartum counseling, and a follow-up mechanism through additional health information and SMS reminders affects continuous contraceptive use and pregnancy incidence among recently postpartum WLWH.

METHODS

We performed a randomized controlled trial between October 2016 and June 2018 at a referral hospital in southwestern Uganda. We included adult WLWH randomized and enrolled in a 1:1 ratio to receive family planning support or standard of care (control) and completed an interviewer-administered questionnaire at enrolment, 6 and 12 months postpartum. Our two primary outcomes of interest were; continuous use of contraception, and incidence of pregnancy. Secondary outcomes included contraception uptake, method change, discontinuation and pregnancy intentions. The trial was registered with clinicaltrials.gov (NCT02964169).

RESULTS

A total of 317(99%) completed all study procedures. Mean age was 29.6 (SD = 6.0) vs 30.0 (SD = 5.9) years for the intervention vs control groups respectively. All women were enrolled on ART. Total women using contraception continuously were 126 (79.8%) in the intervention compared to 110 (69.2%) in control group (odds ratio (OR) = 1.75; confidence interval (CI) = 1.24-2.75, P = 0.003). Pregnancy rates were 2% (N = 3) in the intervention vs 9% (N = 14) in the control group (OR = 0.20, 95% CI = 0.05-0.62, P = 0.006). Pregnancy intention was lower in the intervention vs control group (OR = 0.23, 95% CI = 0.08-0.64, P = 0.002). Women actively enrolled on contraception reduced more in the control compared to the intervention group (OR = 3.92, 95% CI = 1.66-9.77, P = 0.001). Women enrolled on each contraceptive method did not differ by group except for implants. More women initiating contraception use within three months postpartum had better continued use for either intervention (N = 123, 97.6% vs N = 3,2.4%) or control group (N = 86,78.2% vs N = 24,21.8%). Method-related side effects were less reported in the intervention group (OR = 0.25, 95% CI = 0.10-0.60, P = 0.001).

CONCLUSION

We found that sustained and structured family planning support facilitates continuous use of contraception and lowers rates of pregnancy amongst postpartum WLWH in rural southwestern Uganda. Women who initiated contraception within three months postpartum were more likely to maintain continuous use of contraception than those initiating later. Further evaluation of actual and perceived facilitators to the continuous contraception use by this support intervention will help replication in similar settings.

TRIAL REGISTRATION

NCT02964169.

Geographical distribution of fertility rates in 70 low-income, lower-middle-income, and upper-middle-income countries, 2010-16: a subnational analysis of cross-sectional surveys

BACKGROUND

Understanding subnational variation in age-specific fertility rates (ASFRs) and total fertility rates (TFRs), and geographical clustering of high fertility and its determinants in low-income and middle-income countries, is increasingly needed for geographical targeting and prioritising of policy. We aimed to identify variation in fertility rates, to describe patterns of key selected fertility determinants in areas of high fertility.

METHODS

We did a subnational analysis of ASFRs and TFRs from the most recent publicly available and nationally representative cross-sectional Demographic and Health Surveys and Multiple Indicator Cluster Surveys collected between 2010 and 2016 for 70 low-income, lower-middle-income, and upper-middle-income countries, across 932 administrative units. We assessed the degree of global spatial autocorrelation by using Moran's I statistic and did a spatial cluster analysis using the Getis-Ord Gi* local statistic to examine the geographical clustering of fertility and key selected fertility determinants. Descriptive analysis was used to investigate the distribution of ASFRs and of selected determinants in each cluster.

FINDINGS

TFR varied from below replacement (2·1 children per women) in 36 of the 932 subnational regions (mainly located in India, Myanmar, Colombia, and Armenia), to rates of 8 and higher in 14 subnational regions, located in sub-Saharan Africa and Afghanistan. Areas with high-fertility clusters were mostly associated with areas of low prevalence of women with secondary or higher education, low use of contraception, and high unmet needs for family planning, although exceptions existed.

INTERPRETATION

Substantial within-country variation in the distribution of fertility rates highlights the need for tailored programmes and strategies in high-fertility cluster areas to increase the use of contraception and access to secondary education, and to reduce unmet need for family planning.

FUNDING

Wellcome Trust, the UK Foreign, Commonwealth and Development Office, and the Bill & Melinda Gates Foundation.

Gendered social practices in reproductive health: A qualitative study exploring lived experiences of unwed single mothers in China

China's family planning policy has historically silenced the voices of women, especially unwed single mothers at the expense of their reproductive health and overall wellbeing. Further, reproductive decisions in China are closely intertwined with marriage decisions and intergenerational dynamics, highlighting the relevance of gender in women's reproductive health experiences. Chinese unwed single mothers are in particular penalized for violating the gendered social norms supported by the national reproductive policies. Drawing on previous work that calls on the need to explore gender system and its influence on health, this manuscript explores the ways in which gender norms are played out for the unwed single mothers within romantic and intergenerational relations, with impacts on their reproductive health and decision-making. The findings show that reproductive decisions are interwoven with the fulfilment of other gendered identities, such as daughter, daughter-in-law and wife. Although the decision to go through unwed motherhood is reflective of their agency, the tie between childbirth and marriage does not allow the women to entirely break free from the social system. The findings also highlight the importance of considering the role of gender system that is played out within social relations, which in turn impacts the health of the women.

The Effect of Reframing the Goals of Family Planning Programs from Limiting Fertility to Birth Spacing: Evidence from Pakistan

Contraceptive prevalence in Pakistan has plateaued near 34 percent for over a decade, suggesting that fertility levels are likely to stay high unless effective interventions are designed. We evaluate the Family Advancement for Life and Health 2007–2012 (FALAH), a family planning project implemented in 31 districts of Pakistan. Deviating from previous programs, FALAH emphasized birth spacing—as opposed to limiting family size—as the primary purpose of contraceptive use. We use Pakistan Demographic and Health Survey to evaluate FALAH's impact on continuous and binary measures of birth intervals. To estimate the causal effects of the project, we compare the outcomes for multiple children born to the same mother before and after the project. We find that FALAH increased interbirth intervals by 2.4 months on average and reduced the proportion of short birth intervals by approximately 7.1 percentage points. This finding suggests that birth spacing as a goal of contraceptive use may resonate better with Pakistani couples than limiting family size. The project's effects were more pronounced for women with high education, in rural areas, and in the middle of the wealth distribution.

A comparative analysis of the availability of family planning services in the social franchise and non-franchise private health facilities in Kajiado County, Kenya

Introduction

this study assessed the availability of family planning (FP) services in the social franchise and non-franchise private health facilities in Kajiado County, Kenya. Social franchises refer to a standardized delivery model of engaging private health facilities under a common brand name or contractual arrangement.

Methods

this was a facility-based mixed-method approach. Quantitative data was collected through 581 FP client exit interviews and a facility inventory in 32 health facilities. Association between the clients' characteristics and use of FP services was tested using univariable and multivariable logistic regression. Qualitative data were collected through five focus group discussions with FP clients and 16 key informant interviews with service providers and analysed through thematic analysis.

Results

the findings show that FP methods availability was the same across all facilities (p = 0.206). The findings were supported by views from the clients who indicated that contraceptives were available. Statistically significant predictors of FP use were found to be women's age group 20-24 years (Adjusted Odds Ratio (AOR) = 2.30, 95% Confidence Interval (CI): 1.12, 4.69) or 25 to 34 years (AOR = 2.10, 95% CI: 1.86, 2.36) versus the 15-19 years and the clients with tertiary level education and above compared primary level education and below (AOR = 0.020, 95% CI: 1.13, 4.41).

Conclusion

this study demonstrates the need to support all private health facilities with policies and supplies to expand access to all FP services, especially for adolescents.

Awareness and use of family planning methods among women in Northern Saudi Arabia

Background

Evaluation of awareness and use of family planning methods is important to improve services and policies. This study aimed to assess awareness and use of family planning methods among women in an urban community in the north of Saudi Arabia.

A cross-sectional study was carried out in a maternity hospital and 12 primary health care (PHC) centers in Hail City between December 1st, 2019, and May 30, 2020.

Results

Four hundred married sexually active women aged 18–49 years were interviewed using a pretested structured questionnaire. The mean age of the participant was 32.0±7.5 years, 73.5% were university educated, and 58% were housewives. More than two-thirds of them (67.6%) had ≥3 living children. Most women (85%) ever used, and 66.5% were currently using any method of contraception; however, only one in five who get counseling for the contraceptive method used, and 40% of the last births were unplanned for. Almost all women reported unavailable family planning clinics in their primary healthcare centers. Most participants (83.0%) desired to have >3 children, which indicates that the main purpose of family planning was child spacing rather than limitation. Relying on natural methods as being safer (36.3%), desire to have more children (19%), being afraid from side effects (15.3%), and possibility of difficulty getting pregnant or might cause infertility (13.0%) were reasons the participants viewed for unsung modern contraceptives.

Conclusion

This study revealed that most women in urban Hail community, northern Saudi Arabia, were aware about and have a positive attitude towards family planning. The majority of the participants ever used, and two-thirds were currently using any contraceptive method/s, which is higher than the national estimate for Saudi Arabia. However, only one in five counseled by healthcare providers for the type of contraceptive method used. Unavailability of family planning services in primary health care centers impedes getting professional counseling. It is imperious to consider family planning clinics to provide quality family planning services.

Does family planning counseling reduce unmet need for modern contraception among postpartum women: Evidence from a stepped-wedge cluster randomized trial in Nepal

BACKGROUND

Postpartum women have high rates of unmet need for modern contraception in the two years following birth in Nepal. We assessed whether providing contraceptive counseling during pregnancy and/or prior to discharge from the hospital for birth or after discharge from the hospital for birth was associated with reduced postpartum unmet need in Nepal.

METHODS

We used data from a larger a stepped-wedge, cluster randomized trial, including contraceptive counselling in six tertiary hospitals. Group 1 hospitals (three hospitals) initiated the intervention after three months of baseline data collection, while Group 2 hospitals (three hospitals) initiated the same intervention after nine months. We have enrolled 21,280 women in the baseline interviews and conducted two follow-up interviews with them, one and two years after they had delivered in one of our study hospitals. We estimated the effect of counseling and its timing (pre-discharge, post- discharge, both, or neither) on unmet need for modern contraception in the postpartum period, using random-effects logistic regressions.

RESULTS

Unmet need for modern contraception was high (54% at one year and 50% at two years). Women counseled in either the pre-discharge period (Odds ratio [OR] 0·86; 95% CI: 0·80, 0·93) or in the post-discharge period (OR 0·86; 95% CI: 0·79, 0·93) were less likely to have an unmet need in the postpartum period compared to women with no counseling. However, women who received counseling in both the pre- and post-discharge period were 27% less likely than women who had not received counseling to have unmet need (OR 0.73; 95% CI: 0·67, 0·80).

CONCLUSIONS

Counseling women either before or after discharge reduces unmet need for postpartum contraception but counseling in both periods is most effective.

Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up

Background

Health service providers play a key role in addressing women’s need for postpartum pregnancy prevention. Yet, in Nepal, little is known about providers’ knowledge, attitudes, and practice (KAP) on providing postpartum family planning (PPFP), particularly the immediate postpartum intrauterine device (PPIUD). This paper assesses providers KAP towards the provision of PPIUDs in Nepal prior to a PPIUD intervention to gain a baseline insight and analyzes whether their KAP changes both 6 and 24 months after the start of the intervention.

Methods

Data come from a randomized trial assessing the impact of a PPIUD intervention in Nepal between 2015 and 2017. We interviewed 96 providers working in six study hospitals who completed a baseline interview and follow-up interviews at 6 and 24 months. We used descriptive analysis, McNemar’s test and the Wilcoxon signed-rank test to assess KAP of providers over 2 years.

Results

The PPIUD KAP scores improved significantly between the baseline and 6-month follow-up. Knowledge scores increased from 2.9 out of 4 to 3.5, attitude scores increased from 4 out of 7 to 5.3, and practice scores increased from 0.9 out of 3 to 2.8. There was a significant increase in positive attitude and practice between 6 and 24 months. Knowledge on a women’s chance of getting pregnant while using an IUD was poor. Attitudes on recommending a PPIUD to different women significantly improved, however, attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Practice of PPIUD counseling and insertion improved significantly from baseline to 24 months, from 10.4 and 9.4% to 99% respectively.

Conclusions

Although KAP improved significantly among providers during the PPIUD intervention, providers’ knowledge on a women’s chance of getting pregnant while using an IUD and attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Provider KAP could be improved further through ongoing and more in-depth training to maintain providers’ knowledge, reduce provider bias and misconceptions about PPIUD eligibility, and to ensure providers understand the importance of birth spacing.

Family Planning Uptake in Kagera and Mara Regions in Tanzania: A Cross-Sectional Community Survey

In Tanzania, 27.1% of all women of reproductive age are currently using modern contraception and 16.8% have an unmet need for family planning. We therefore examined factors associated with family planning uptake after giving birth in two regions of Tanzania. The survey, which collected information beyond that collected in the Tanzania Demographic Health Survey, used a two-stage, stratified-cluster sampling design, conducted in April 2016 in Mara and Kagera regions in Tanzania. A total of 1184 women aged 15-49 years, who had given birth less than two years prior to the survey were included. Logistic regression mixed effect modelling was used to examine factors associated with family planning uptake. A total of 393 (33.2%) women used family planning methods and 929 (79%) required prior approval from their partners. Participation of men in utilization of maternal health care was low, where 680 (57.8%) women responded that their partners accompanied them to at least one antenatal care (ANC) counselling visit and 120 (10%) responded that their partners participated in family planning counselling. Women who did not want to disclose whether they had discussed family planning with their partners, strikingly had the highest percentage of using family planning methods after birth. Factors independently associated with family planning uptake included: having discussed family planning with the partner (aOR 3.22; 95% CI 1.99-5.21), having been counselled on family planning during antenatal care (aOR 2.68; 95% CI 1.78-4.05), having discussed family planning with a community health worker (CHW) (aOR 4.59; 95% CI 2.53-8.33) and with a facility health care worker (aOR 1.93; 95% CI 1.29-2.90), having primary or higher educational level (aOR 1.66; 95% CI 1.01-2.273), and being in union (aOR 1.86; 95% CI 1.02-3.42). Educational interaction with community and facility health workers, as well as having a supportive partner as facilitator increased uptake of family planning. This needs to be prioritized in regions with similar socio-cultural norms in Tanzania and beyond.

Obstacles socioculturels liés à l’utilisation de la contraception moderne en Côte d’Ivoire

INTRODUCTION

In C&#244;te d&#8217;Ivoire, national modern contraceptive prevalence remains low, at 21% in 2017.Purpose of research: The objective of this study was to identify socio-cultural obstacles related to the use of modern contraception among women of reproductive age.

METHODS

We conducted a descriptive and qualitative study in Dallas, in the Adjam&#233; commune, located in the center of Abidjan. The survey took place from 9th June to 7th July&#160;2018. In addition, we conducted four focus groups with men over 20 years old, women of reproductive age between 15 and 49 years old, and two religious leaders recruited according to a reasoned sampling. Group discussion guides and individual interview guides were used as data collection tools. Moreover, we analyzed data after recording and transcribing, following a thematic content analysis.

RESULTS

We interviewed thirty participants including 14 men, 14&#160;women, and two religious leaders. The main obstacles described were the lack of reliable and adequate information, misconceptions about contraception, fear of side effects, illiteracy, male decision-making power, religious prohibitions, and the socio-cultural contradictions. To circumvent these obstacles, women secretly used contraceptives, thereby exposing themselves to social risks.

CONCLUSION

Our study highlighted the persistence of socio-cultural practices. For that reason, taking into account people&#8217;s perceptions is necessary to improve the use of modern contraception at the community level.

Factors influencing maternal health choices among women of reproductive age in Hausa communities in Ibadan, Nigeria: an exploratory study

Introduction

decision making is a vital aspect of women's reproductive life. In an attempt to fulfil the desire to procreate, women's lives are lost especially in developing countries where medical care is still inadequate. The researchers sought to explore the Hausa people's culture as regards maternal health choices concerning modern family planning methods, delivery places and parity.

Methods

a cross-sectional study using mixed methods was conducted among women of reproductive age (N=253) in three Hausa communities in Ibadan. Based on the objectives, semi-structured questionnaire and in-depth interview guide were used for data collection. Quantitative data were analysed using Chi-square and the level significance set at 0.05 while qualitative data were analysed thematically.

Results

over fifty percent respondents had more than 3 children and about one third (33.9%) preferred having more than 4 children. Nearly all participants (94%) were aware of modern family planning methods but only 49.0% used them. The most widely used methods are injectables (22.0%) and condoms (20.6%). Almost half of the study population (46.5%) delivered their babies at home with assistance from other residents with most preferring home delivery for various reasons.

Conclusion

although the level of awareness about family planning methods is quite satisfactory, however, the level of contraceptive uptake is still sub-optimal. Most Hausa women prefer home delivery which predisposes them to associated complications. Findings further identified various reasons for maternal health choices and provided insights on viable nursing interventions that can be adopted to promote skilled birth delivery to reduce maternal morbidity and mortality.

Unmet contraceptive needs among female sex workers (FSWs) in semi urban Blantyre, Malawi

Background

Research has paid limited attention to understanding factors that are associated with unmet contraceptive needs among female sex workers. In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined associated factors among FSWs in semi urban Blantyre, Malawi.

Methods

We used systematic sampling to recruit 290 female sex workers in semi urban Blantyre between February and March 2019. In this cross sectional study, we used questionnaire interviews to collect quantitative data. We calculated the mean and standard deviation for continuous variables and proportions for categorical variables to describe the data. Logistic regression analysis was used to investigate the association between unmet needs (the outcome variable) and explanatory variables such as: having a steady partner, fear of contraceptives’ side effects and having a history of sexually transmitted infections.

Results

Out of the 290 study participants 102 (35.2%) reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: female sex workers’ history of physical and sexual violence by clients [OR 3.38, 95% CI (1.10, 10.43)], p < 0.03, participants with a steady partner [OR 3.28, 95% CI (1.89, 5.68)], p < 0.001, and participants who feared side effects of contraceptives [OR 2.99, 95% CI (1.73, 5.20)], p < 0.001.

Conclusion

Reproductive Health services should address barriers to contraceptives use for instance: violence by female sex workers’ clients, fear and misinformation on contraceptives. There is need to improve awareness of contraceptives. Specific health promotion interventions on female sex workers engaged in a steady partnership are recommended. It is important to enhance the knowledge, attitudes, and counseling skills of health care providers in order to address unmet contraceptive needs among female sex workers in semi-urban Blantyre.

Plain English summary

Unmet contraceptive needs are defined as lack of contraceptives use in heterosexually active women of childbearing age who do not wish to become pregnant. Unmet contraceptive needs are the main cause of short inter-pregnancy intervals, early childbearing, physical abuse, unintended pregnancy, poor maternal and child health outcomes. Several studies have documented low contraceptives use among female sex workers (FSWs), but research has paid limited attention to understanding factors associated with unmet contraceptive needs among this population in semi urban Blantyre Malawi.

In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined factors that were associated with unmet contraceptive needs among FSWs in semi urban Blantyre, Malawi. We recruited 290 FSWs and collected quantitative data. These data were analyzed to obtain descriptive statistics. Logistic regression analysis was used to investigate the association between unmet contraceptive needs (the outcome variable) and explanatory variables such as: FSWs with history of physical and sexual violence by clients, having a steady partner, fear of contraceptives’ side effects and having a history of sexually transmitted infections.

Out of the 290 FSWs, 35% reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: FSWs’ history of physical and sexual violence by clients, participants with a steady partner and participants who feared contraceptive side effects.

Sexual and Reproductive Health services should address barriers to contraceptives use, female sex workers exposure to violence, having a steady partners and concerns about side effects. There is also a need to improve the knowledge, attitudes, and counseling skills of health providers in order to address unmet contraceptive needs among FSWs.

Context-acceptability theories: example of family planning interventions in five African countries

BACKGROUND

Family planning (FP) can lengthen birth intervals and potentially reduce the risk of foetal death, low birthweight, prematurity, and being small for gestational age. Effective FP is most easily achieved through access to and acceptability of modern contraceptive methods (MCMs). This study aimed to identify mechanisms of acceptability and the contexts in which they are triggered and to generate theories to improve the selection and implementation of effective interventions by studying an intervention integrating FP with childhood immunisation services.

METHODS

Qualitative interpretative synthesis of findings from realist evaluations of FP interventions in five African countries was guided by an analytical framework. Empirical mechanisms of acceptability were identified from semi-structured interviews and focus group discussions with key stakeholders (N = 253). The context in which these mechanisms were triggered was also defined. Empirical mechanisms of acceptability were matched to constructs of a theoretical framework of acceptability. Context-acceptability theories (CATs) were developed, which summarised constructs of acceptability triggered for specific actors in specified contexts. Examples of interventions that may be used to trigger acceptability for these actors were described.

RESULTS

Seven CATs were developed for contexts with strong beliefs in religious values and with powerful religious leaders, a traditional desire for large families, stigmatisation of MCM use, male partners who are non-accepting of FP, and rumours or experiences of MCM side effects. Acceptability mechanisms included alignment with values and beliefs without requiring compromise, actors' certainty about their ability to avoid harm and make the intervention work, and understanding the intervention and how it works. Additionally, acceptability by one group of actors was found to alter the context, triggering acceptability mechanisms amongst others.

CONCLUSIONS

This study demonstrated the value of embedding realist approaches within implementation research. CATs are transferable theories that answer the question: given the context, what construct of acceptability does an intervention need to trigger, or more simply, what intervention do we need to apply here to achieve our outcomes? CATs facilitate transfer of interventions across geographies within defined contexts.

Joint Predictors of Hypertension and Type 2 Diabetes Among Adults Under Treatment in Amhara Region (North-Western Ethiopia)

BACKGROUND

One of the chronic diseases, all over the world, due to its significant contribution to the existence of other health problems is hypertension. It is known that hypertensive patients exposed to diabetes and the reverse is also true. The objective of the current investigation was to identify joint risk factors for hypertension and type 2 diabetes for adults under treatment.

METHODS

A random sample of 748 hypertensive and type 2 diabetic patients was selected. A retrospective longitudinal study was conducted with the selected patients who were receiving treatment for both hypertension and type 2 diabetes. A joint linear mixed-effect model was used for data analysis in this investigation.

RESULTS

The current investigation revealed that age (β = 0.18, p-value = 0.04 for hypertension, β = 0.81, p-value = 0.02 for type 2 diabetes) and weight of patients (β = 0.52, p-value <0.01 for hypertension, β = 0.32, p-value <0.01 for type 2 diabetes) were positively and significantly associated with existence of hypertension and type 2 diabetes whereas visiting times (β = -0.08, p-value = 0.04 for hypertension, β = -0.38, p-value = 0.03 for type 2 diabetes) were negatively associated with the variables of interest. Similarly, patients who do not exercise, who smoke, and drink and patients with a family history of disease were positively associated with the existence of the variables of interest.

CONCLUSION

Hypertension and diabetes are highly correlated and one is the causes of the other. Hypertensive and diabetic patients should be aware that they should stop drinking alcohol and smoking and should attend properly to their medication as prescribed by health staff. They should also be advised to undertake physical exercise to reduce risks related to these two correlated diseases.

Are myths surrounding long-acting reversible contraception the reason for a huge unmet need for spacing pregnancies?

Background:

Long-acting reversible contraceptives (LARC), a highly effective class of contraceptives, has a limited uptake by few couples due to lack of awareness, unavailability, and myths surrounding their application and side effects.

Aims:

This study was undertaken to understand and to clear myths of LARC among patients as well as to assess the knowledge, attitudes, practices, and preference.

Materials and Methods:

A hospital-based cross-sectional study using a semistructured questionnaire was conducted in the out-patient Department of Obstetrics and Gynecology, in a tertiary level hospital in Eastern India. A total of 600 women responded to the structured validated questionnaire.

Results:

High prevalence of teenage marriages (64%), teenage pregnancies (44%), and unwanted pregnancy (41%) was noted among responders. The knowledge scores were low in 66.7%, moderate in 26.66%, and only 6.66% had high level >80% scores in the 15 questions about LARC methods. While 41% had a positive attitude to future use of LARC, a majority (59%) had a strong negative attitude due to many myths of genital tract infections, discharges, and cancer, changed menstrual bleeding patterns, delayed conception after discontinuation, and altered sexual functions. Out of those with a positive attitude, 21% of women had a preference for intrauterine devices, 19.5% of women for injectables, and only 0.5% of women preferred contraceptive implants. 24.5% of women had used LARC in their lifetime but a meager 5% were currently using them.

Conclusions:

The study shows that there is a huge unmet need for spacing contraceptive methods as childbearing spacing is not maintained. There were lack of correct knowledge and awareness, and numerous myths surrounding LARC methods.

Utilization of Long-Acting Reversible Contraceptives and Associated Factors Among Reproductive Age Women Attending Governmental Health Institutions for Family Planning Services in Wondo Genet District, Sidama, National Regional State, Southern Ethiopia

BACKGROUND

Utilization of family planning services improves women's reproductive health outcomes. Long-acting reversible contraceptive (LARCs) methods, in particular, prevent unwanted pregnancy and significantly reduce maternal mortality and morbidity. In Ethiopia utilization of LARCs was very low. Therefore, this study was aimed at assessing the utilization of LARCs and associated factors among reproductive-age women in Wondo Genet District, Southern Ethiopia.

METHOD

Institution based cross-sectional study was conducted from 15 May to 15 August 2020 among reproductive-age women. A systematic sampling method was applied to recruit 376 women and the sample size was allocated to health centers proportionally. Data collection was conducted by trained collectors using pretested and structured questionnaires. Data coded and entered into EPI Info 7 and the analysis was done using SPSS version 25. Binary and multiple logistic regression analyses were done. Statistical significance was declared with P < 0.05.

RESULT

The utilization of LARCs was 37.8% (95% CI: 32.9-42.7). The multivariable analysis showed that odds of the utilization of LARCs were increased among reproductive-aged ≥25 years (Adjusted odds ratio (AOR) = 2.21, 95% CI: 1.04, 4.41), gave birth to ≥3 live births (AOR = 2.2, 95% CI: 1.2, 4.04), employed (AOR = 1.92, 95% CI: 1.17, 3.14), earned high monthly income (AOR = 2.02, 95% CI: 1.25, 3.26) and discussed contraceptive methods with their husbands (AOR = 2.87, CI: 1.68, 4.89].

CONCLUSIONS

Utilization of LARCs was low. The odds of the utilization of LARCs were increased in women aged ≥25 years, gave birth to 3 or more children, earned high monthly income, and discussed with their husbands about contraception methods.

Determinants of Postpartum Contraception Use Among Teenage Mothers in Eastern Uganda: A Cross-Sectional Study

Introduction

In Uganda, the proportion of women having another live birth before age 20 years (repeat adolescent birth) has not declined in 30 years. More women want to delay the next birth. We determined the prevalence and factors associated with postpartum contraceptive use among teenage mothers in Mbale City.

Patients and Methods

We conducted a cross-sectional study in all the six government-supported health facilities within Mbale City. Over a period of 3 months, 511 teenage mothers in the postpartum period were consecutively enrolled by midwives/nurses. Data were collected using a pretested interviewer-administered questionnaire. We used logistic regression in STATA version 14, to determine the association between various sociodemographic characteristics and utilization of contraception. We set the level of significance at 5% and report odds ratios and the corresponding 95% confidence intervals.

Results

Most of the respondents - 314/511 [61.5%, 95% CI= 57.1-65.6%] - were using contraceptives. More than three-fourth (238/314) of the respondents opted for short-term methods of contraception. In the adjusted analyses, intention to resume school [AOR 1.79 (1.16-2.74)], and utilization of maternal Child Heath services such as postnatal care services [AOR 0.40 (0.25-0.63)] were significantly associated with utilisation of postpartum contraception.

Conclusion

We found a high prevalence of postpartum contraceptives use - over 6 in 10 women - although they were using mainly short-term methods. Those with intentions of resuming schooling and utilised postnatal care services were most likely to use contraceptives. This is encouraging and calls for inquiry into why their use is higher than the national averages. Further, the results call for renewed efforts to maintain adolescent mothers in school.

Preventing maternal mortality in the United States: lessons from California and policy recommendations

Maternal mortality remains a large concern in the United States (US), although other Western countries are making progress. In this scoping review, we identify four problems that may contribute to the maternal mortality burden in the US: inadequately investing in women's health, poor quality of care, increasing disparities, and poor data collection and monitoring of maternal health issues. Because maternal mortality is decreasing in California, we identify strategies implemented there that could improve maternal health outcomes nationwide: funding programs to address social determinants of maternal health; supporting health care strategies to improve maternal health (including national standards and goals for health care systems); and investing in maternal health monitoring and surveillance (including use of technology). We encourage researchers, practitioners, and policymakers to work together to develop evidence-based policies and practices to improve maternal health and reduce maternal. We conclude with recommendations for the United States and globally.

Self-Deception about Fecundity in Women : Modeling the Burley Hypothesis

Concealed fecundity and extended female sexual receptivity have evolved in some primates, including humans, conferring advantages both within primarily monogamous relationships (e.g., benefits from paternity assurance) and from extrapair liaisons (e.g., better access to good genes). As humans evolved the intellectual capacity for decision-making, women became capable of altering their own fertility. In some circumstances, they may choose to ameliorate risks and responsibilities associated with pregnancy by reducing sexual motivation near the perceived most fecund time of their menstrual cycle. But three findings-a general inability of women to accurately recognize their own intervals of fecundity, high variability in ovulation timing, and unconscious transmission and reception of cues associated with fecundity-constitute a physiological and behavioral syndrome that can be considered self-deception. In this study, I develop a descriptive model to determine implications of the hypothesis that these features of female and male physiology and behavior have been shaped by natural selection in response to female decision-making. My analysis shows that consensus motivation for coitus between partners influences both the importance of variable ovulation date and the probability of conception, under the influence of self-deception. It also identifies priorities for future empirical work.

Assessment of emergency contraceptives utilization and associated factors among female college students at Debre Tabor town

Background

Unwanted pregnancy is a significant public health problem worldwide. In higher education, students are exposed to the risk of unintended pregnancy, abortion, and its related negative consequences.

Objective

The objective of this study was to assess the magnitude of emergency contraceptives and factors associated with its utilization among college female students at Debre Tabor Town, Northwest Ethiopia.

Methods

A cross-sectional, institutional-based study was conducted from June to October 2017. A multi-stage stratified sampling technique was applied to select the study participants. Data were cleaned, coded, and entered into Epi info 7 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regression was used to identify the association between the use of emergency contraception and the predictor variables. The P-value less than 0.05 at 95% CI was taken as statistical significance.

Results

A total of 821 respondents participated with a response rate of 97.6%. The finding showed that 33.3% of them have used emergency contraceptives following unprotected sex. Female students’ knowledge about emergency contraceptive [AOR: 2.3; 95% CI 1.20, 4.25], age with 20–24 years category [AOR: 2.3; 95% CI 1.21, 4.49] and married [AOR: 2.8; 95% CI 1.22, 6.21] and divorced [AOR: 4.9; 95% CI 1.12, 21.08] students were found to be significant predictors of EC utilization.

Conclusions

This study revealed that the level of emergency contraceptive utilization was low. Students’ level of knowledge about an emergency contraceptive, age at present, and marital status were found to be the major predictor for emergency contraceptive utilization. Therefore, responsible bodies should develop strategies that enhance the knowledge level of students at the college level on the effective utilization of emergency contraceptive methods.

Beyond ‘Family Planning’—Local Realities on Contraception and Abortion in Ouagadougou, Burkina Faso

Family planning has long been promoted within international health efforts because of its potential benefits for controlling population growth, reducing poverty and maternal and child mortality, empowering women, and enhancing environmental sustainability. In Burkina Faso, the government and donor partners share a commitment to ‘family planning’, notably by increasing the low uptake of ‘modern’ contraceptive methods in the general population and reducing recourse to induced abortion, which remains legally restricted. This paper presents ethnographic findings that show the complexity of family planning within the social context of women’s lives and care-seeking trajectories. It draws on participant observation in Ouagadougou, Burkina Faso’s capital, and interviews with women with a wide range of reproductive experiences and providers of family planning services. First, the paper shows that women’s use of contraceptive methods and abortion is embedded in the wider social dilemmas relating to marriage, sexuality, and gendered relationships. Second, it shows that women use contraceptives to meet a variety of needs other than those promoted in public health policies. Thus, while women’s use of contraceptive methods is often equated with family planning within public health research and health policy discourse, the uses women make of them imbue them with other meanings related to social, spiritual, or aesthetic goals.

Factors promoting sustainability of NURHI programme activities in Ilorin and Kaduna, Nigeria: findings from a qualitative study among health facility staff

OBJECTIVES

The Nigerian Urban Reproductive Health Initiative (NURHI) was implemented in six urban sites in Nigeria from 2009 to early 2015. Under a second phase (NURHI-2), activities ceased operations in four of the original six sites in 2015 (Ilorin, Abuja, Benin City and Zaria), and continued in two sites (Kaduna and Ibadan). This paper examines the sustainability of facility-based intervention activities implemented under NURHI-1 in Ilorin and Kaduna.

METHODS

A qualitative study that used in-depth interviews was conducted with 31 service providers purposively selected from 10 of the NURHI-1 intervention facilities in Ilorin and six in Kaduna. Interviews were digitally recorded and transcripts uploaded into ATLAS.ti for analysis. Structured observations to document renovations implemented during the NURHI-1 interventions were also conducted in the health facilities.

RESULTS

Family planning (FP) awareness creation within the facilities and integration of FP into existing maternal and child health and HIV services, were sustained in both cities. The majority of the equipment supplied as part of the NURHI 72-hour clinic makeover were still functional in both cities. Respondents in both cities reported that FP awareness and demand were sustained. On the whole, challenges with sustaining activities were reported more among respondents in Ilorin than Kaduna. In Ilorin, NURHI outreach activities and trainings, had discontinued while in Kaduna, they were no longer being implemented to the same degree as occurred during NURHI-1. Inadequate funds was a major reason for discontinued activities in both cities while integration of FP into existing services enhanced sustainability.

CONCLUSIONS

Many activities were not sustained in Ilorin compared with Kaduna although FP awareness and demand remained high in both cities. Integration of FP into existing services promoted sustainability in Ilorin and Kaduna. A gradual closeout of donor projects with concomitant input from government and indigenous institutions could be useful in sustaining donor activities.

A risk scoring tool for predicting Kenyan women at high risk of contraceptive discontinuation

Objective

We developed and validated a pragmatic risk assessment tool for identifying contraceptive discontinuation among Kenyan women who do not desire pregnancy.

Study design

Within a prospective cohort of contraceptive users, participants were randomly allocated to derivation (n = 558) and validation (n = 186) cohorts. Risk scores were developed by selecting the Cox proportional hazards model with the minimum Akaike information criterion. Predictive performance was evaluated using time-dependent receiver operating characteristic curves and area under the curve (AUC).

Results

The overall contraceptive discontinuation rate was 36.9 per 100 woman-years (95% confidence interval [CI] 30.3–44.9). The predictors of discontinuation selected for the risk score included use of a short-term method or copper intrauterine device (vs. injectable or implant), method continuation or switch (vs. initiation), < 9 years of completed education, not having a child aged < 6 months, and having no spouse or a spouse supportive of family planning (vs. having a spouse who has unsupportive or uncertain attitudes towards family planning). AUC at 24 weeks was 0.76 (95% CI 0.64–0.87) with 70.0% sensitivity and 78.6% specificity at the optimal cut point in the derivation cohort. Discontinuation was 3.8-fold higher among high- vs. low-risk women (95% CI 2.33–6.30). AUC was 0.68 (95% CI 0.47–0.90) in the validation cohort. A simplified score comprising routinely collected variables demonstrated similar performance (derivation-AUC: 0.73 [95% CI 0.60–0.85]; validation-AUC: 0.73 [95% CI 0.51–0.94]). Positive predictive value in the derivation cohort was 31.4% for the full and 28.1% for the simplified score.

Conclusions

The risk scores demonstrated moderate predictive ability but identified large proportions of women as high risk. Future research is needed to improve sensitivity and specificity of a clinical tool to identify women at high risk for experiencing method-related challenges.

Implications

Contraceptive discontinuation is a major driver of unmet contraceptive need globally. Few tools exist for identifying women who may benefit most from additional support in order to meet their contraceptive needs and preferences. This study developed and assessed the validity of a provider-focused risk prediction tool for contraceptive discontinuation among Kenyan women using modern contraception. High rates of early discontinuation observed in this study emphasize the necessity of investing in efforts to develop new contraceptive technologies and stronger delivery systems to better align with women's needs and preferences for voluntary family planning.

Prevalence and factors associated with early discontinuation rate of Implanon utilization among women who ever used Implanon in Kucha District Gamo Gofa Zone, Southern Ethiopia

Background

The promotion of contraception in countries with high birth rates has the potential to reduce poverty, hunger, maternal, and childhood deaths. Every year in sub-Saharan Africa approximately 14 million unintended pregnancies occurred and a sizeable proportion was due to poor use of short-term hormonal methods. Contraceptive hormonal implants are highly effective and suitable for almost all women at any stage of their reproductive lives. On the other hand, early discontinuation of the Implanon contraceptive method utilization is one of the foremost problems amid the family planning program. Early discontinuation of the Implanon contraceptive method and reasons for such discontinuation lingers the most significant anxiety for family planning programs. In unindustrialized countries, contraceptive discontinuation due to health concerns is generally higher; these complaints are often related to service quality. Hence, this study aimed to assess the prevalence and factors associated with early discontinuation of Implanon among women who ever used Implanon in Kucha district, Gamo Gofa Zone, Southern Ethiopia.

Methods

Implanon contraceptive device users were selected from the Kucha district using a cross-sectional community-based survey from January to March 2018. A total of 430 women were selected and data were collected through face-to-face interviews by using a pre-tested structured questionnaire. Data were cleaned, coded, and entered into Epi-Info version 7statistical software. Factors that showed association in a bivariate analysis that has a p value of less than 0.25 were entered into multiple logistic regression models for controlling confounding factors. The strength of statistical association was measured by adjusted odds ratio, at 95% confidence intervals, and p value < 0.05 were considered as statistically significant variables.

Result

The result of this study revealed that the overall discontinuation rate of Implanon in the study was 34%. Variables having statistically significant association with Implanon discontinuation were women who never use a contraceptive method other than Implanon (AOR = 2.96, 95% CI 1.53–5.74), women who didn’t make discussion with a partner (AOR = 3.32, 95% CI 1.57–7.04), poor counseling and follow up (AOR = 9.23, 95% CI 4.7–18.13), fear of side effects (AOR = 0.12, 95% CI 0.058- 0.24) and poor satisfaction of service (AOR = 5.2, 95% CI 2.77- 9.76)

Conclusion

The overall early discontinuation rate of Implanon in the study area was high. The main factors associated with early discontinuation of Implanon were contraceptive ever use, discussion with partner, poor follow-up of counseling, fear of side effects, and un-satisfaction by the services given during the insertion rate of Implanon.

Individual and contextual factors associated with mistimed and unwanted pregnancies among adolescent girls and young women in selected high fertility countries in sub-Saharan Africa: A multilevel mixed effects analysis

Introduction

Unintended pregnancies are associated with a number of risk factors such as malnutrition, mental illness, unsafe abortion, maternal mortality and horizontal transmission of HIV to children. These risks are predominant among adolescent girls and young women compared to older women. This study examined the individual and contextual factors associated with unintended pregnancy among adolescent girls and young women in selected high fertility countries in sub-Saharan Africa.

Materials and methods

Data for this study was obtained from recent Demographic and Health Surveys carried out between 2010 and 2018 in 10 countries in sub-Sahara Africa. The sample size for this study was made up of 6,791 adolescent girls and young women (aged 15–24), who were pregnant during the surveys and had complete responses on all the variables considered in the study. Unintended pregnancy was the outcome variable in this study. Descriptive and multilevel logistic regression analyses were performed and the fixed effect results of the multilevel logistic regression analysis were reported as adjusted odds ratios at 95% confidence interval.

Results

Unintended pregnancy in the selected countries was 22.4%, with Angola, recording the highest prevalence of 46.6% while Gambia had the lowest prevalence of 10.2%. The likelihood of unintended pregnancy was high among adolescent girls and young women aged 15–19 [aOR = 1.48; 95% CI = 1.26–1.73], those with primary [aOR = 1.99; 95% CI = 1.69–2.33] and secondary/higher [aOR = 2.30; 95% CI = 1.90–2.78] levels of education, single (never married/separated/divorced/widowed) adolescent girls and young women [aOR = 9.23; 95% CI = 7.55–11.28] and those who were cohabiting [aOR = 2.53; 95% CI = 2.16–2.96]. The odds of unintended pregnancy also increased with increasing birth order, with adolescent girls and young women having three or more births more likely to have unintended pregnancies compared to those with one birth [aOR = 1.99; 95% CI = 1.59–2.48]. Adolescent girls and young women who had ever used contraceptives (modern or traditional), had higher odds of unintended pregnancies compared to those who had never used contraceptives [aOR = 1.32; 95% CI = 1.12–1.54]. Finally, adolescent girls and young women who belonged to the rich wealth quintile were more likely to have unintended pregnancy compared to those in the poor wealth quintile [1.28; 95% CI = 1.08–1.51].

Conclusion

The study found that age, marital status, level of education, parity, use of contraceptives and wealth quintile are associated with unintended pregnancy among adolescent girls and young women in high fertility sub-Saharan African countries. These findings call for the need for government and non-governmental organisations in high fertility sub-Saharan African countries to restructure sexual and reproductive health services, taking into consideration these individual and contextual level characteristics of adolescent girls and young women.

Spatial variations and associated factors of modern contraceptive use in Ethiopia: a spatial and multilevel analysis

OBJECTIVE

To assess spatial variations in modern contraceptive use and to identify factors associated with it among married women in Ethiopia.

DESIGN

Cross-sectional analysis of population-based and health facility data.

SETTING

Ethiopia Demographic and Health Survey data linked to Service Provision Assessment data.

POPULATION

8473 married women and 1020 facilities that reported providing family planning services.

METHODS

A linked secondary data analysis of population and health facility data was carried out. Both multilevel and spatial analyses were conducted to identify key determinants of women's use of modern contraceptive and spatial clustering of modern contraceptive use.

MAIN OUTCOME MEASURE

Modern contraceptive use.

RESULTS

About 24% of the variation in the use of modern contraception was accounted for by location. A one-unit increase in the mean score of health facilities' readiness to provide short-term modern contraceptives in a typical region was associated with a 20-fold increase in the odds of modern contraceptive use (adjusted OR (AOR) 20.49, 95% CI 1.44 to 29.54). In the spatial analysis, it was found that Addis Ababa and the Amhara region had high clusters of modern contraceptive use rates. On the other hand, low rates of contraceptive use were clustered in the Afar and Somali regions.

CONCLUSION

There were significant variations in the use of modern contraceptives across the different regions of Ethiopia. Therefore, regions with low contraceptive rates and high fertility rates should be targeted for scaling up and tailoring of services to the culture and lifestyles of the population of those regions.

Lactational amenorrhoea among adolescent girls in low-income and middle-income countries: a systematic scoping review

INTRODUCTION

Fertility levels among adolescents remain high in many settings. The objective of this paper was to review the available literature about postpartum and lactational amenorrhoea among adolescents in low-income and middle-income countries (LMICs).

METHODS

We searched Medline, Embase, Global Health and CINAHL Plus databases using terms capturing adolescence and lactational or postpartum amenorrhoea. Inclusion criteria included publication date since 1990, data from LMICs, and topic related to lactational amenorrhoea as a postpartum family planning method or as an effect of (exclusive) breast feeding among adolescents. Thematic analysis and narrative synthesis were applied to summarise and interpret the findings.

RESULTS

We screened 982 titles and abstracts, reviewed 75 full-text articles and included nine. Eight studies assessed data from a single country (three from India, two from Bangladesh, two from Turkey, one from Nigeria). One study using Demographic and Health Survey data included 37 different LMICs. The five studies measuring duration of postpartum or lactational amenorrhoea reported a wide range of durations across the contexts examined. Four studies (from Bangladesh, Nigeria and Turkey) examined outcomes related to the use of lactational amenorrhoea as a family planning method among adolescents. We did not find any studies assessing adolescents' knowledge of lactational amenorrhoea as a postpartum family planning method. Likewise, little is known about the effectiveness of lactational amenorrhoea method among adolescents using sufficiently large samples and follow-up time.

CONCLUSION

The available evidence on lactational amenorrhoea among adolescents in LMICs is scarce. Given the potential contribution of lactational amenorrhoea to prevention of short interpregnancy intervals among adolescents and young women, there is a need for a better understanding of the duration of lactational amenorrhoea, and the knowledge and effective use of lactational amenorrhoea method for family planning among adolescents in a wider range of LMIC settings.

Family planning awareness, utilization and associated factors among women of reproductive age attending psychiatric outpatient care, a cross- sectional study, Addis Ababa, Ethiopia

BACKGROUND

Women with mental illness have a special need for family planning as they carry a high risk of unplanned pregnancy, sexual violence and, the poor obstetric outcomes due to their mental illness, as well as teratogenicity from exposure to psychotropic medications lower antenatal care utilization.

OBJECTIVE

To assess knowledge, and utilization of family planning and associated factors among women attending psychiatric outpatient clinics in Addis Ababa.

METHODS

A cross-sectional study was conducted among 423 women attending the outpatient psychiatric clinics of three general and one specialized mental hospital in Addis Ababa, the capital city of Ethiopia. A structured and pretested questionnaire were administered by psychiatric nurses. Multiple logistic regression analysis was conducted to identify factors associated with utilization of family planning methods.

RESULT

Four hundred twenty-two participants who had follow up at the psychiatric outpatient departments participated in the study. Almost 88% of participants had an unintended pregnancy. Only 68% of study participant had ever heard about Family planning. Just over one third (38.6%) reported current use of at least one method of Family planning. Of those not using family planning 73.3% had no intention to have children. And 38.8% did not have any intention to use Family Planning in the future. Fear of drug-interaction with psychiatric medication was the most common reason not to use contraceptives. Having one or two children was associated with higher utilization of family planning [adjusted odds ratio (95%, confidence interval) 2.05 (1.06, 3.99)].

CONCLUSIONS

In this study, the majority of women with mental illness were not using family planning methods. The Awareness of the Family planning methods is lower than the national average. Education and counselling about family planning for women attending psychiatric outpatient departments should be strengthened.