Measurement of unmet need for family planning: longitudinal analysis of the impact of fertility desires on subsequent childbearing behaviors among urban women from Uttar Pradesh, India

Childbearing plans' predictive value for birth outcomes: A systematic review to inform mode of delivery decisions

OBJECTIVE

Rising cesarean delivery (CD) rates significantly impact maternal health, underscoring the need for comprehensive counseling. This review examines the consistency of childbearing plans over time and their predictive value for childbirth events.

DATA SOURCES

PubMed, EMBASE, Web of Science, and PsycINFO databases up to October 2023.

STUDY ELIGIBILITY CRITERIA

Studies assessing women's childbearing plans at baseline (T1) and following up with subsequent plans and/or outcomes (T2).

STUDY APPRAISAL AND SYNTHESIS METHODS

Meta-analyses calculated risk ratios and standardized mean differences using random-effects models. Bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Forty-four studies (n = 132,846 women) were included. Average desired family size at T1 was 2.63 (95 %CI: 2.03-3.23), remaining stable at follow-up (p = 0.135). While no significant change in plans was observed for women who initially wanted children, negative plans showed significant instability (pooled effect size: 0.18, 95 %CI: 0.03-0.33; p = 0.0162). Estimated rates of stable, decreasing, and increasing childbearing plans were 74 %, 12 %, 11 %, respectively. Positive plans strongly predicted childbirth (RR = 3.95, 95 % CI: 2.46, 6.35; p < 0.0001; I2 = 98 %). Follow-up childbirth rates for initially negative plans were 5 % (95 % CI: 0-44 %) for nulliparae, 13 % (95 % CI: 2-57 %) for primiparae, and 64 % (95 % CI: 61-68 %) formultiparae.

CONCLUSIONS

On average, women desire 2.63 children (95 % CI: 2.03-3.23). Childbearing plans are largely stable, but around 10 % of women with negative or uncertain plans later desired children. Positive plans nearly quadrupled childbirth likelihood. Negative plans were less predictive, particularly in multiparous women. Future research should explore age, socioeconomics, and cultural contexts, particularly for nulliparous women over 35 considering elective CD.

Pregnancy intentions and outcomes among young married women in Nepal

Background

Approximately 44% of Nepalese women ages 15-49, desiring to avoid pregnancy, do not use modern contraceptives, resulting in an estimated 539,000 unintended pregnancies annually.

Objectives

This study aims to investigate the association between young, newly married women's pregnancy intentions and subsequent pregnancies.

Study design

Data were collected longitudinally from 200 recently married women ages 18-25 in Nepal. Surveys conducted every six months over 18 months covered various health domains. The study used mixed-effects logistic regression models to account for repeated measurement of correlated data over time. The primary outcome was pregnancy. Pregnancy intention was determined based on responses to, "When would you like to have a child in case you were to have one?" Participants were recategorized into a dichotomous variable for analytical purposes: "Right away" or "Not right away."

Results

A total of 133 participants became pregnant during the study, with sociodemographic characteristics showing minimal differences between pregnant and nonpregnant groups. Women intending to become pregnant right away had significantly higher odds of becoming pregnant (OR, 4.03; 95% CI, 2.51-6.48) after adjusting for covariates. Among those not intending immediate pregnancy, over 70% became pregnant, suggesting potential barriers to achieving reproductive goals.

Conclusions

Young, newly married women in Nepal intending immediate pregnancy have higher odds of becoming pregnant. However, a substantial proportion of those hoping to delay pregnancy still experience unintended pregnancies, indicating challenges in meeting reproductive goals. The findings underscore the need for addressing barriers to contraceptive access and societal norms impacting women's reproductive autonomy in Nepal.

Life skills and reproductive health empowerment intervention for newly married women and their families to reduce unintended pregnancy in India: protocol for the TARANG cluster randomised controlled trial

INTRODUCTION

In South Asia, younger women have high rates of unmet need for family planning and low empowerment. Life skills interventions can equip young women with agency, but the effectiveness of these interventions in reproductive and sexual autonomy and contraception has not been examined.

METHODS AND ANALYSIS

A two-arm, parallel, cluster randomised controlled trial will evaluate the impact of TARANG (Transforming Actions for Reaching and Nurturing Gender Equity and Empowerment), a life skills and reproductive health empowerment group-based intervention for newly married women, compared with usual services in the community in rural and tribal Rajasthan, India. TARANG will also provide light-touch sessions to husbands and mothers-in-law of newly married women. We will test the impact of TARANG in 80 village clusters among 800 eligible households comprising newly married women aged 18-25 years who are at risk of pregnancy but do not want a pregnancy within 1 year at the time of enrolment, their husbands and mothers-in-law who consent to participate. Women in the intervention villages will receive 14 sessions over a 6-month period, while husbands and mothers-in-law will receive 1 and 4 sessions (respectively) each. Three rounds of surveys will be collected over 18 months. Control villages will receive the intervention after the endline surveys. Primary outcomes include rate of unintended pregnancy and modern contraceptive use. We plan to start recruitment of participants and data collection in April 2024. We will estimate unadjusted and adjusted intention-to-treat effects using survival analysis and mixed models.

ETHICS AND DISSEMINATION

Study protocols have been reviewed and approved by the human subjects review boards at the University of California, San Francisco, and the Centre for Media Studies, India (IRB00006230) and ACE Independent Ethics Committee, Bangalore (NET0062022). Results will be disseminated in international peer-reviewed journals and conferences, to stakeholders including local government and non-governmental organisations, and directly to the communities and individuals that participated in the intervention.

TRIAL REGISTRATION NUMBER

NCT06024616.

Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs

Despite its central importance to global family planning, the "unmet need for contraception" metric is frequently misinterpreted. Often conflated with a lack of access, misinterpretation of what unmet need means and how it is measured has important implications for family planning programs. We review previous examinations of unmet need, with a focus on the roles of access and demand for contraception, as well as the role of population control in shaping the indicator's priorities. We suggest that disaggregating unmet need into "demand-side unmet need" (stemming from lack of demand) and "supply-side unmet need" (stemming from lack of access) could allow current data to be leveraged into a more person-centered understanding of contraceptive need. We use Demographic and Health Survey data from seven sub-Saharan African countries to generate a proof-of-concept, dividing women into unmet need categories based on reason for contraceptive nonuse. We perform sensitivity analyses with varying conceptions of access and disaggregate by education and marital status. We find that demand-side unmet need far exceeds supply-side unmet need in all scenarios. Focusing on supply-side rather than overall unmet need is an imperfect but productive step toward person-centered measurement, while more sweeping changes to family planning measurement are still required.

Longitudinal examination of young married women's fertility and family planning intentions and how they relate to subsequent family planning use in Bihar and Uttar Pradesh India

OBJECTIVES

This study examines which fertility and family planning (FP) intentions are related to subsequent FP use in a sample of young, married women in India.

DESIGN

We use 3-year longitudinal data from married women ages 15-19 in 2015-2016 (wave 1) who are not using contraception to examine factors associated with any use of FP in 2018-2019 (wave 2).

SETTING

Data were collected in the states of Bihar and Uttar Pradesh, India.

PARTICIPANTS

A representative sample of 4893 young married women ages 15-19 was surveyed in 2015-2016 and 4000 of them were found and interviewed 3 years later. This analysis focused on the 3614 young women who were not using FP at wave 1.

PRIMARY OUTCOMES

This study examines FP use at wave 2 as the main outcome variable.

RESULTS

Multivariate analyses demonstrated that young women who wanted to delay childbearing three or more years or who did not want any(more) children at wave 1 were more likely to use contraception at wave 2. Additionally, intention to use FP in the next 12 months at wave 1 was significantly associated with FP use at wave 2 whereas unmet need at wave 1 was not significantly related to subsequent use. A combined measure of fertility desires and intention to use FP demonstrated the importance of both measures on subsequent use. Having any children and being pregnant at wave 1 were both related to FP use at wave 2.

CONCLUSIONS

It is important to reach young, married women prior to a first pregnancy with nuanced messages addressing their fertility and FP intentions. Programmes targeting women at antenatal and postpartum visits are important for young women to help support them to use FP to address their desires to delay or limit future childbearing for the health and well-being of themselves and their children.

Embodiment, agency, unmet need: Young women's experiences in the use and non-use of contraception in Khayelitsha, South Africa

Globally, high rates of unintended pregnancy occur despite widespread distribution of modern contraceptive methods, reflecting the complexity of individual contraceptive use. The concept of unmet need provides a framework for addressing the gap between women's desire to prevent pregnancy and the ability of health services to meet women's contraceptive needs. Through in-depth interviews in Khayelitsha, South Africa, we examine 14 young women's experiences with contraception, interrogating how and why reproductive intentions and outcomes often differ markedly. Three main themes were identified and explored. First, unintended pregnancies were common in our sample, despite high knowledge about contraceptive options and availability of multiple methods. Second, women's contraceptive preferences are strongly shaped by concerns with side effects and other embodied experiences, leading to pivotal moments of method-switching or cessation of contraceptive use. Third, using contraception provides participants with the potential for purposeful and self-directed action. These enactments of agency though, occur within intimate and familial relationships, where gendered expectations of the participants' choices ultimately shape both method preference and use. These findings demonstrate the need for an understanding of women's lives and narratives as the basis for understanding complex health behaviours such as contraceptive use.

Language and Measurement of Contraceptive Need and Making These Indicators More Meaningful for Measuring Fertility Intentions of Women and Girls

We examine current “need”-based family planning measures that are based on women’s fertility desires and contraceptive use, identify challenges with language and use of need-based measures, and recommend ways to improve language and measurement.

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study

BACKGROUND

An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes.

METHODS

The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight.

RESULTS

Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention.

CONCLUSIONS

We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.

A Panel Study of Fertility Preferences and Contraceptive Dynamics in the Presence of Competing Pregnancy Risks in Uganda

Although many studies have examined the influence of women's fertility preferences on subsequent fertility behavior and the role of contraceptive use intentions on unmet need, very few have explored their concurrent effects on contraceptive use dynamics. This study examines the independent concurrent effects of women's fertility preferences and contraceptive intentions on subsequent adoption and discontinuation, treating pregnancy as a competing risk factor that may alter contraceptive need. The data are derived from a 2018 follow-up survey of a 2014 national sample of 3,800 Ugandan female respondents of childbearing age. The survey included a contraceptive calendar that recorded pregnancy, birth, and contraceptive event episodes, including reasons for discontinuation. We use competing risk regression to estimate the effect of fertility preferences and contraceptive intentions on the cumulative incidence function of contraceptive behaviors, accounting for intervening pregnancy, female background covariates, loss to follow-up, and complex survey design. We find that women's contraceptive intentions significantly increase the rate of contraceptive adoption. After having adopted, women's contraceptive intentions have been realized and do not prolong use. The risk of discontinuation among women who adopted after baseline was significantly higher than for those using at baseline, irrespective of their initial intentions. The effectiveness of the type of contraceptive method chosen significantly lowered discontinuation risk. Fertility preferences were not significantly associated with either time to adoption or discontinuation. The pace of the fertility transition in this sub-Saharan African setting is likely being shaped by reproductive regulation through the intentional use of contraception that enables spacing births.

Investigating the Relationship between Food Insecurity and Fertility Preferences in Tanzania

OBJECTIVE

We analyze fertility preferences among women at risk of pregnancy with children ages five or younger as a function of two food security metrics: perceptions of household hunger and child stunting (height for age z scores ≤ -2.0) in order to convey a robust picture of food insecurity.

METHODS

We use data from the 2016 Tanzania Demographic and Health Surveys to analyze this research question. Multinomial generalized logit models with cluster-adjusted standard errors are used to determine the association between different dimensions of food insecurity and individual-level fertility preferences.

RESULTS

On average, women who experience household hunger are 19% less likely to want more children compared to women who do not experience household hunger (AOR: 0.81, p = 0.02) when controlling for education, residence, maternal age, number of living children, and survey month. Adjusting for the same covariates, having at least one child ≤ 5 years old who is stunted is associated with 13% reduced odds of wanting more children compared to having no children stunted (AOR: 0.87, p = 0.06).

CONCLUSIONS FOR PRACTICE

In the context of a divided literature base, this research aligns with the previous work identifying a preference among women to delay or avoid pregnancy during times of food insecurity. The similarity in magnitude and direction of the association between food insecurity and fertility preferences across the two measures of food insecurity suggest a potential association between lived or perceived resource insecurity and fertility aspirations. Further research is needed in order to establish a mechanism through which food insecurity affects fertility preferences.

SIGNIFICANCE STATEMENT

Individual fertility preferences are sensitive to dynamic multi-level factors in a woman's life. While qualitative research has explored the effect that food insecurity and associated resource constraints have on fertility preferences, results are conflicting. Here, we quantitatively examine how individual woman's fertility preferences associate with two measures of food insecurity and qualitatively compare the associations across food insecurity measures. We establish that two food insecurity measures- household hunger and child stunting- capture similar populations and have similar associations with fertility preferences. This is a critical step forward in understanding the dynamic relationship between resource availability, child well-being, and fertility preferences.

Disentangling the effects of reproductive behaviours and fertility preferences on child growth in India

We analysed population data from the 2015-16 National Family Health Survey to disentangle the intricate underlying effects of reproductive behaviours and fertility preferences on child growth. We expected birth interval length to be more strongly associated with stunting than sibsize and these effects to be moderated by whether the child was wanted or unintended (mistimed/unwanted). Regression analyses showed strong and equal effects of short birth interval and sibsize on stunting, when adjusted for potential confounders and unobserved between-mother heterogeneity. There were no statistical associations between stunting and mistiming/unwantedness of index children, suggesting the absence of discrimination against such children. We conclude that while fertility preferences have no effect, reproductive behaviours exert significant influence on child growth. Sibsize has been falling for many years in India but birth interval lengths have remained largely unchanged. The results underscore the need for strengthening uptake of reversible contraceptives to enable longer birth intervals.

A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: what works and what doesn't?

AIM

The aim of this systematic review was to synthesise the evidence on the comparative effectiveness of different counselling strategies for modern contraception on contraceptive behaviour and satisfaction, and to examine their advantages and disadvantages.

METHODS

Six electronic databases (Medline, Embase, Global Health, Popline, CINAHL Plus, and Cochrane Library) were searched to identify publications comparing two or more contraceptive counselling strategies and reporting quantitative results on contraceptive use, uptake, continuation or switching, or client satisfaction. Studies of women or couples from any country, published in English since 1990 were considered.

RESULTS

A total of 63 publications corresponding to 61 studies met the inclusion criteria. There was substantial heterogeneity in study settings, interventions and outcome measures. Interventions targeting women initiating a method (including structured counselling on side effects) tended to show positive effects on contraceptive continuation. In contrast, the majority of studies of provider training and decision-making tools for method choice did not find evidence of an effect. Additional antenatal or postpartum counselling sessions were associated with increased postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. Dedicated pre-abortion contraceptive counselling was associated with increased use only when accompanied by broader contraceptive method provision. Male partner or couples counselling was effective at increasing contraceptive use in two of five studies targeting non-users, women initiating implants or seeking abortion. High-quality evidence is lacking for the majority of intervention types.

CONCLUSIONS

The evidence base and quality of studies are limited, and further research is needed to determine the effectiveness of many counselling interventions in different settings.

Sociodemographic factors and prenatal care behaviors associated with unplanned pregnancy in a Brazilian birth cohort study

OBJECTIVE

To identify the sociodemographic factors and prenatal behavior characteristics associated with unplanned pregnancy.

METHODS

A cross-sectional survey was conducted of mothers of newborns enrolled in a birth cohort in Ribeirão Preto, Brazil. Questionnaires were administered to postpartum women. Multiple logistic regression was used to identify sociodemographic predictors of unplanned pregnancy and to evaluate the association with adherence to prenatal care recommendations.

RESULTS

The cohort included 7608 mothers: 7541 (99.1%) answered the interview and 4056 (53.8%) had an unplanned pregnancy. Adolescents were more likely to have an unplanned pregnancy (odds ratio [OR] 1.87; 95% confidence interval [CI] 1.50-2.34) as were women over 40 (OR 1.74; 95% CI 1.22-2.47). Pregnancy during adolescence (OR 1.27; 95% CI 1.09-1.48), being single (OR 7.56; 95% CI 5.98-9.56), having two or more previous births (OR 1.73; 95% CI 1.52-1.97), and being of a lower socioeconomic status were also predictors. Lack or late initiation of prenatal care, attendance at less than six prenatal visits, drinking alcohol, and smoking during pregnancy were associated with unplanned pregnancy.

CONCLUSION

Unplanned pregnancies disproportionately affect women at extremes of age, single, and of low socioeconomic status. These women are less likely to adhere to prenatal care.

The relationship between attitudes towards pregnancy and contraceptive continuation: Results from a longitudinal study of married women in India

To understand the relationship between pregnancy intentions and contraceptive use, a growing body of research has begun to examine various domains of women's attitudes towards pregnancy, acknowledging that these attitudes may contradict one another, and women may be ambivalent. This study examines pregnancy ambivalence and assesses the relationship between attitudes towards pregnancy and contraceptive continuation after nine months among a sample of women in Odisha and Haryana, India. Data come from a longitudinal study of married women age 15–49 who began using a modern reversible method of contraception at the time of study enrollment. To assess their cognitive attitudes (beliefs/knowledge) towards pregnancy, women were asked “how important is it you to avoid a pregnancy now?” To assess their affective attitudes (feelings/emotions), women were asked about their agreement with the statement: “If I found out I was pregnant in the next several weeks, I would be happy.” A joint, 4-category measure combining these cognitive and affective attitudes towards pregnancy was created to measure concordance and ambivalence in attitudes towards pregnancy. Multivariate random-effects logistic regression models were employed to examine the relationship of these two measures with method-specific contraceptive continuation nine months later. Two models were conducted, one with the two attitude variables included independently and the second with the joint, 4-category measure included. Results showed that affective and cognitive attitudes were both significantly associated with continuation, but that there were no significant differences between those that were ambivalent and those whose attitudes were concordantly anti-pregnancy. This study suggests that attitudes towards pregnancy are multifaceted and both cognitive and affective attitudes towards pregnancy may play an important role in contraceptive use in India.

The role of change in fertility desire on change in family planning use: A longitudinal investigation in urban Uttar Pradesh, India

Background: Reproductive choice is one of the rights of any woman, but women are often ambivalent towards fertility desires and choice of contraception. Our study explores how the change in fertility desires influence the change in use of modern contraception over time in six cities of Uttar Pradesh, India. Methods : Data for this study comes from the Measurement, Learning and Evaluation (MLE) Project for Urban Health Initiative in six cities of Uttar Pradesh. Our study sample consists of 8735 women (weighted n=8655) who were fertile, non-sterilized and non-pregnant at the time of baseline survey. Potential bias due to lost to follow up was addressed using inverse probability weighing and then generalized estimating equations were applied to get odds for change in use of modern contraceptives.  Results: Contraceptive use increased by different magnitudes from baseline to endline across all six cities. At baseline and endline, women who desired no more children reported a higher use of modern contraception than those who desired more children over time. Women from all cities who desired no more children at baseline had higher odds of modern contraceptive use than that of women who desired more children. The tempo of change in use of modern contraception over time among women with different fertility desires differed across the considered cities. Conclusion : Although there were city-wise differences observed, women's fertility intentions have an impact on their use of modern contraceptives over the time period between baseline to endline. To obtain greater insight into city-level differences, mixed method studies will be more effective.

The role of change in fertility desire on change in family planning use: A longitudinal investigation in urban Uttar Pradesh, India

Background: Reproductive choice is one of the rights of any woman, but women are often ambivalent towards fertility desires and choice of contraception. Our study explores how the change in fertility desires influence the change in use of modern contraception over time in six cities of Uttar Pradesh, India. Methods: Data for this study comes from the Measurement, Learning and Evaluation (MLE) Project for Urban Health Initiative in six cities of Uttar Pradesh. Our study sample consists of 8735 women (weighted n=8655) who were fertile, non-sterilized and non-pregnant at the time of baseline survey. Potential bias due to lost to follow up was addressed using inverse probability weighing and then generalized estimating equations were applied to get odds for change in use of modern contraceptives.  Results: Contraceptive use increased by different magnitudes from baseline to endline across all six cities. At baseline and endline, women who desired no more children reported a higher use of modern contraception than those who desired more children over time. Women from all cities who desired no more children at baseline had higher odds of modern contraceptive use than that of women who desired more children. The tempo of change in use of modern contraception over time among women with different fertility desires differed across the considered cities. Conclusion: Although there were city-wise differences observed, women’s fertility intentions have an impact on their use of modern contraceptives over the time period between baseline to endline. To obtain greater insight into city-level differences, mixed method studies will be more effective.

Barriers to postpartum contraception: differences among women based on parity and future fertility desires

Timely use of contraception in the postpartum year is critical for pregnancy spacing, which protects a mother's health and improves her ability to care for children. This qualitative study explored contraceptive decision-making among postpartum women in Nairobi, Kenya, with a focus on accounts of how women overcame barriers to postpartum contraceptive use. Focus groups (n = 61) and in-depth interviews (n = 30) explored experiences, barriers and actual use of postpartum contraception. Data were analysed using framework analysis, a method that organises qualitative data into themes and then interprets the data by mapping participant characteristics to these themes. Contraceptive use among women who desired future fertility was hindered by fear of side-effects and concern for partner disapproval. However, women who were satisfied with their family size more easily overcame these barriers. Tailoring postpartum contraceptive counselling to both assuage the concerns of women who desire future fertility and address the long-term contraceptive needs of mothers who desire to stop child-bearing could play a role in reducing the unmet need for contraception. .

Sex composition and its impact on future childbearing: a longitudinal study from urban Uttar Pradesh

Background

The sex composition of existing children has been shown to influence childbearing decision-making and behaviors of women and couples. One aspect of this influence is the preference for sons. In India, where son preference is deeply entrenched, research has normally focused on rural areas using cross-sectional data. However, urban areas in India are rapidly changing, with profound implications for childbearing patterns. Yet, evidence on the effect of the sex composition of current children on subsequent childbearing intentions and behavior in urban areas is scant. In this study, we analyze the impact of sex composition of children on subsequent (1) parity progression, (2) contraceptive use, and (3) desire for another child.

Methods

We analyze prospective data from women over a four year period in urban Uttar Pradesh using discrete-time event history logistic regression models to analyze parity progression from the first to second parity, second to third parity, and third to fourth parity. We also use logistic regression models to analyze contraceptive use and desire for another child.

Results

Relative to women with no daughters, women with no sons had significantly higher odds of progressing to the next birth (parity 1 – aOR: 1.31; CI: 1.04–1.66; parity 2 – aOR: 4.65; CI: 3.11–6.93; parity 3 – aOR:3.45; CI: 1.83–6.52), as well as reduced odds of using contraception (parity 2 – aOR:.58; CI: .44–.76; parity 3 – aOR: .58; CI: .35–.98). Relative to women with two or more sons, women with two or more daughters had significantly higher odds of wanting to have another child (parity 1 – aOR: 1.33; CI: 1.06–1.67; parity 2 – aOR: 3.96; CI: 2.45–6.41; parity 3–4.89; CI: 2.22–10.77).

Conclusions

Our study demonstrates the pervasiveness of son preference in urban areas of Uttar Pradesh. We discuss these findings for future programmatic strategies to mitigate son preference in urban settings.

Factors affecting the achievement of fertility intentions in urban Nigeria: analysis of longitudinal data

BACKGROUND

Maternal mortality ratio in Nigeria is among the highest in the world with an estimated 160 women dying every day of complications related to pregnancy and childbirth. In addition to appropriate management of complications related to pregnancy and childbirth, preventing unwanted pregnancies is an effective way to reduce maternal deaths. Identifying potentially modifiable factors associated with the achievement of fertility intentions is critical for developing behavior change interventions that will contribute to reducing maternal mortality.

METHODS

The data analyzed came from a longitudinal design with data collected in 2010/2011 and 2014 from the same group of women of reproductive age in six Nigerian cities. The data were collected as part of efforts to evaluate the effects of the Nigerian Urban Reproductive Health Initiative (NURHI). A total of 10,672 women were interviewed at the two points in time but the analyses in this manuscript were limited to 1921 in-union women who reported that they desired no more children at baseline in 2010/2011. The principal analytic method was multivariable regression adjusted for clustering at the enumeration area level. The analysis controlled for socio-demographic and household variables, ideational characteristics, and contraceptive use at baseline.

RESULTS

About two thirds of the women who desired no more children at baseline have neither had any children nor were pregnant at endline. The strongest predictors of the achievement of fertility intentions include parity, age, religion, residence, spousal communication about family size, perceived severity of another pregnancy, and spousal agreement about family size.

CONCLUSION

A comprehensive strategy to help women avoid unwanted pregnancies should include efforts to increase women's understanding about effective ways to prevent unplanned pregnancies and strengthen self-efficacy for contraceptive use. Promoting spousal communication about reproductive issues, engaging men, promoting smaller family sizes and changing pronatalist attitudes should also be part of such a strategy.

Fear, opposition, ambivalence, and omission: Results from a follow-up study on unmet need for family planning in Ghana

INTRODUCTION

Despite a relatively strong family planning program and regionally modest levels of fertility, Ghana recorded one of the highest levels of unmet need for family planning on the African continent in 2008. Unmet need for family planning is a composite measure based on apparent contradictions between women's reproductive preferences and practices. Women who want to space or limit births but are not using contraception are considered to have an unmet need for family planning. The study sought to understand the reasons behind high levels of unmet need for family planning in Ghana.

METHODS

A mixed methods follow-up study was embedded within the stratified, two-stage cluster sample of the 2014 Ghana Demographic and Health Survey (GDHS). Women in 13 survey clusters who were identified as having unmet need, along with a reference group of current family planning users, were approached to be reinterviewed within an average of three weeks from their GDHS interview. Follow-up respondents were asked a combination of closed- and open-ended questions about fertility preferences and contraceptive use. Closed-ended responses were compared against the original survey; transcripts were thematically coded and analyzed using qualitative analysis software.

RESULTS

Among fecund women identified by the 2014 GDHS as having unmet need, follow-up interviews revealed substantial underreporting of method use, particularly traditional methods. Complete postpartum abstinence was sometimes the intended method of family planning but was overlooked during questions about method use. Other respondents classified as having unmet need had ambivalent fertility preferences. In several cases, respondents expressed revised fertility preferences upon follow-up that would have made them ineligible for inclusion in the unmet need category. The reference group of family planning users also expressed unstable fertility preferences. Aversion to modern method use was generally more substantial than reported in the GDHS, particularly the risk of menstrual side effects, personal or partner opposition to family planning, and religious opposition to contraception.

Family planning in Southern India: A survey of women's attitudes

Women were recruited from villages in the Belgaum district of India. Members of the research team obtained consent and led 58 interviews in the local languages. Participants were asked questions covering topics related to postpartum contraceptive counseling, knowledge, and experience; postpartum sexual practice; birth spacing desire and counseling; and interest in long-acting reversible contraceptives (LARCs). Women generally desired 3 years of birth spacing. A majority did not receive counseling regarding postpartum contraception during the prenatal period, although most would have liked to have received such counseling. Those who had made a contraceptive plan during the prenatal period had an odds ratio of 25.2 (95% CI 4.9-128.6, p = 0.00001) for using postpartum contraception. Influences on contraceptive decisions primarily came from friends and family, while information from medical providers was not a major influence. Most women did not believe they could make their own decisions regarding contraception use, but those who did had an adjusted odds ratio of 56 (95% CI 3.4-9161, p = 0.0047) of utilizing postpartum contraception. Women generally liked the idea of LARCs. A large majority of the women surveyed (89.66%) liked the idea of a subdermal contraceptive implant, a method currently unavailable in this region. Ultimately, the women surveyed do have healthy attitudes and goals regarding birth spacing but few utilize effective contraception in order to meet their goals. Further efforts in counseling as well as availability of a wider variety of contraceptive methods, including the subdermal contraceptive implant, may decrease the disparity between desires and practices.

Unmet reproductive health needs among women in some West African countries: a systematic review of outcome measures and determinants

Background

Identifying relevant measures of women’s reproductive health needs is critical to improve women’s chances of service utilization. The study aims to systematically review and analyze the adequacy of outcome measures and determinants applied in previous studies for assessing women reproductive health needs across West Africa.

Methods

Evidence on outcomes and determinants of unmet reproductive health needs among women of childbearing age in diverse multicultural, religious, and ethnic settings in West African countries was systematically reviewed. The review included recent English language publications (from January 2009 - March 2014). Clinical studies particularly on obstetric care services and reproductive services in relation to HIV/AIDS were excluded. We acknowledge the possibility to have excluded non-English publications and yet-to-be-published articles related to the study aim and objectives. Outcomes and determinants were assessed and defined at three main levels; contraceptive use, obstetric care, and antenatal care utilization.

Results

Results show increasing unmet need for women’s reproductive health needs. Socio-cultural norms and practices resulting in discontinuation of service use, economic constraints, travel distance to access services and low education levels of women were found to be key predictors of service utilization for contraception, antenatal and obstetric care services. Outcome measures were mainly assessed based on service utilization, satisfaction, cost, and quality of services available as core measures across the three levels assessed in this review.

Conclusions

Evidence from this review indicates that currently applied measures of women’s reproductive health needs might be inadequate in attaining best maternal outcomes since they appear rather broad. More support and research for developing and advancing context-related measures may help to improve women’s maternal health.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0104-x) contains supplementary material, which is available to authorized users.

Fertility desires, family planning use and pregnancy experience: longitudinal examination of urban areas in three African countries

Background

Many women have inconsistent fertility desires and contraceptive use behaviors. This increases their risk of unintended pregnancies. Inconsistencies may reflect barriers to family planning (FP) use but may also reflect ambivalence toward future childbearing. Using urban data from Kenya, Nigeria, and Senegal, this study examines the role of fertility desires and FP use behaviors on pregnancy experience over a 2-year follow-up period.

Methods

Data come from baseline and 2-year follow-up among urban women interviewed in Kenya, Nigeria, and Senegal. At baseline (2010/2011), women were asked about their future fertility desires (want child soon, want to delay >2 years, does not want) and current FP use. At midterm (2012/2013), women were asked if they were currently pregnant or had a birth in the 2-year period. We examine the association between baseline fertility desires and FP use with pregnancy experience and desirability of an experienced pregnancy.

Results

In the 2-year follow-up period, 27–39 % of women in union experienced a pregnancy or birth. In Kenya and Nigeria, 30–35 % of women using a modern FP method experienced a pregnancy/birth; the percentage with a pregnancy/birth was slightly higher among women not using at baseline (41 % in both countries). In Senegal, the distinction between pregnancy experience between users and non-users was greater (16 % vs. 31 %, respectively). In all countries, pregnancy was less common among users of long-acting and permanent methods; only a small percentage of women use these methods. Women not wanting any(more) children were the least likely to experience a pregnancy in the 2-year follow-up period. No differences were observed between those who wanted to delay and those who wanted soon. Multivariate findings demonstrate distinctions in pregnancy experience by fertility desires among modern FP users. Non-users have similar pregnancy experience by fertility desires.

Conclusions

Fertility desires are not stable; providers need to consider the fluidity of fertility desires in counseling clients. Programs focusing on new FP users may miss women who are the most motivated to avoid a pregnancy and need to switch to a more effective method; this will result in less unintended pregnancies overall.

An Assessment of Childbearing Preferences in Northern Malawi

Fertility preferences are an essential component of family planning program evaluation; however, doubts about their validity in sub-Saharan Africa exist and little methodological assessment has been carried out. This study investigates prospective fertility intentions in terms of their temporal stability, intensity, degree of spousal agreement, and association with future childbearing in northern Malawi. A total of 5,222 married women participated in the three-round study. The odds of having a child or becoming pregnant within 36 months were 4.2 times higher when both wife and husband wanted a child within three years and 2 times higher when both wanted to wait at least three years, compared with the odds when both wanted to cease childbearing. The influence of husbands’ and wives’ preferences on subsequent fertility was equal. Compared with the intention to stop, the intention to postpone childbearing was less stable, recorded less spousal agreement, and was much less strongly predictive of fertility.

Identifying factors that influence pregnancy intentions: evidence from South Africa and Malawi

In developing-country settings, pregnancy intentions are often assessed using a series of questions from the Demographic and Health Surveys, yet research conducted in several countries yields conflicting results regarding these questions' ability to predict pregnancy. Conducted in Malawi and South Africa, this study identified individual, partner and societal factors that influence desire for pregnancy, and women's ability to achieve their intentions. Data come from interviews and focus-group discussions conducted prior to the FEM-PrEP HIV-prevention trial with women from communities at high risk of HIV infection. Cultural norms regarding contraceptive use and childbearing influenced both women's desire for pregnancy and ability to achieve those goals. Partner's expectations for pregnancy, financial concerns, family composition and contraceptive experiences were additional influences. Actively planning for pregnancy was not a salient concept to the majority of participants. Results support the call for a multidimensional measure of pregnancy intention that reflects the variety of factors that influence intentions, highlight the fluid nature of many women's reproductive health decision making and challenge the notion that all fertility decisions are the result of conscious action. Additional work on how women's plans for pregnancy are achieved would be programmatically more useful than current measures of intention.

Male experiences of unintended pregnancy: characteristics and prevalence

STUDY QUESTION

What are the characteristics and circumstances of pregnancies men report as unintended in France?

SUMMARY ANSWER

Pregnancies reported as unintended were most prevalent among young men with insecure financial situations, less stable relationships and inconsistent use of contraception or false assumptions about their partner's use of contraception.

WHAT IS KNOWN ALREADY

Efforts to involve men in family planning have increased over the last decade; however, little is known about factors associated with men's pregnancy intentions and associated contraceptive behaviours.

STUDY DESIGN, SIZE, DURATION

The data presented in this study were drawn from the nationally representative FECOND study, a population-based survey conducted in France in 2010. The sample comprised 8675 individuals (3373 men), aged 15-49 years, who responded to a telephone interview about socio-demographics and topics related to sexual and reproductive health. The total refusal rate was 20%.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included 2997 men, of whom 664 reported 893 recent pregnancies (in the 5 years preceding the survey). Multivariate Poisson's regression with population-averaged marginal effects was applied to assess the individual and contextual factors associated with men's intentions for recent pregnancies. The contraceptive circumstances leading to the unintended pregnancies were also assessed.

MAIN RESULTS AND THE ROLE OF CHANCE

Of all heterosexually active men, 5% reported they had experienced an unintended pregnancy with a partner in the last 5 years. A total of 20% of recent pregnancies reported by men were qualified to be unintended, of which 45% ended in induced abortion. Of pregnancies following a previous unintended pregnancy, 68% were themselves unintended. Among all heterosexually active men, recent experience of an unintended pregnancy was related to age, mother's education, age at first sex, parity, contraceptive method history, lifetime number of female partners and the relationship situation at the time of survey. Recent unintended pregnancies were also related to pregnancy order and to the financial and professional situation at the time of conception. The majority of unintended pregnancies occurred when men or their partners were using contraceptives; 58% of contraceptive users considered that the pregnancy was due to inconsistent use and 39% considered that it resulted from method failure. Half of the non-users who reported an unintended pregnancy thought that their partner was using a contraceptive method. The relative risk of non-use of a contraceptive method during the month of conception of a recent unintended pregnancy was higher among those without a high school degree (IRR = 2.9, CI 1.6, 5.2) and higher among men for whom the pregnancy interfered with education (IRR = 1.8, CI 1.0, 3.1) or work (IRR = 1.9, CI 1.1, 3.6).

LIMITATIONS, REASONS FOR CAUTION

From the perspective of men, the unintended pregnancy rates may be underestimated due to a combination of underreporting of abortion and post-rationalization of birth intentions. Our use of a dichotomous measure of unintended pregnancy is unlikely to fully capture the multidimensional construct of pregnancy intentions.

WIDER IMPLICATION OF THE FINDINGS

These results call for gender-inclusive family planning programmes, which fully engage men as active participants in their own rights.

STUDY FUNDING/COMPETING INTERESTS

The FECOND study was supported by a grant from the French Ministry of Health, a grant from the French National Agency of Research (#ANR-08-BLAN-0286-01; PIs N.B., C.M.), and funding from National Institute of Health and Medical Research (INSERM) and the National Institute for Demographic Research (INED). None of the authors have competing interests.

Understanding patterns of temporary method use among urban women from Uttar Pradesh, India

Background

Almost one in five contraceptive users in India uses a temporary method. It is important to understand user profiles and method use patterns for optimal program targeting.

This analysis examines differences in demographic characteristics, discontinuation and use patterns of temporary method users among a representative sample of urban women from four cities in Uttar Pradesh, India.

Methods

Individual data from a panel of women aged 15–49 were collected in 2010 in Agra, Aligarh, Allahabad, and Gorakhpur and follow-up data from the same women were collected in 2012. A contraceptive calendar was used to collect month-by-month data on contraceptive use, non-use, discontinuation, reason for discontinuation, and pregnancy and birth, covering the approximately two-year period between the baseline and midterm surveys. The analysis sample is 4,023 non-sterilized women in union at baseline. A descriptive comparison is made of socio-demographic characteristics, fertility desires, discontinuation, method switching, and pregnancy outcomes. Reasons for discontinuation are assessed by the order of discontinuation.

Results

There were a number of socio-demographic differences between users of temporary methods during the calendar period; by education, wealth, and caste. Notably, women who used only condoms during this time had the most education, were the least likely to be poor, and the least likely to be from a scheduled caste or tribe as compared to users of other temporary methods. Compared to the full sample of women, users of temporary methods during this period were less likely to reside in slum areas. The group of multiple method users was small in comparison to the groups of women using a single method throughout the calendar period. This indicates that there was little method switching between condoms, traditional methods, and other forms of modern methods reported in the calendar.

Conclusions

The calendar may not be well-suited to measure coital-dependent contraceptive use (e.g., condoms and traditional methods), as "continuous" monthly use may be overstated. A coital episode-specific data collection tool may produce more accurate records of contraceptive use in such contexts. Research findings also lead to useful programmatic recommendations for addressing unmet need and unintended pregnancies in urban Uttar Pradesh and beyond.

Bucking social norms: examining anomalous fertility aspirations in the face of HIV in Lusaka, Zambia

In settings of high fertility and high HIV prevalence, individuals are making fertility decisions while simultaneously trying to avoid or manage HIV. We sought to increase our understanding of how individuals dually manage HIV risk while attempting to achieve their fertility goals as part of the project entitled HIV Status and Achieving Fertility Desires conducted in Zambia in 2011. Using multivariate regression to predict fertility patterns based on socio-demographic characteristics for respondents from facility-based and community-based surveys, we employed Anomalous Case Analysis (ACA) whereby in-depth interview respondents were selected from the groups of outliers amongst the survey respondents who reported lower or higher fertility preferences than predicted as well as those who adhered to predicted patterns, and lived in Lusaka (n=45). All of the facility-based respondents were HIV-positive. We utilize the Theory of Conjunctural Action (TCA) to categorize domains of influence on individuals' preferences and behavior. Both community-based and facility-based right-tail respondents (outliers whose fertility intentions indicated that they wanted a/nother child when we predicted that they did not) expressed comparatively less control over their fertility and gave more weight to pressures from others to continue childbearing. Partner communication about fertility desires was greater among left-tail respondents (outliers whose fertility intentions indicated that they did not want a/nother child when we predicted that they did). HIV-positive right-tail respondents were more likely to see anti-retroviral therapies (ARTs) which prevent mother to child transmission of HIV as highly effective, mitigating inhibitions to further childbearing. Drug interactions between ARTs and contraceptives were identified as a limitation to HIV-positive individuals' contraceptive options on both sides of the distribution. Factors that should be taken into account in the future to understand fertility behavior in high HIV-prevalent settings include couples' communication around fertility and perception of the efficacy of ARTs.

The effect of family sex composition on fertility desires and family planning behaviors in urban Uttar Pradesh, India

BACKGROUND

A cultural preference for sons has been well documented in India, resulting in skewed sex ratios, especially exhibited in northwest India. Previous research has shown that family sex composition is associated with family planning (FP) use and couples' desire for more children. This study examines family sex composition and fertility and FP behaviors in urban Uttar Pradesh, India; little work has examined these issues in urban settings where family sizes are smaller and FP use is common.

METHODS

Data for this analysis comes from a 2010 representative survey of married, non-pregnant fecund women aged 15-49 from six cities in Uttar Pradesh, India. Multivariate analyses are used to examine the association between family sex composition and fertility desires and FP use.

RESULTS

The multivariate results indicate that family sex composition is associated with fertility desires and FP use. Women without living children and without at least one child of each sex are significantly less likely to want no more children and women with both sons and daughters but more sons are significantly more likely to want no more children as compared to women that have both sons and daughters but more daughters. Women with no living children and women with daughters but no sons are less likely to be modern FP users than nonusers whereas women with both sons and daughters but more sons are more likely to be modern FP users than nonusers as compared to women with both sons and daughters but more daughters.

CONCLUSIONS

These findings confirm that family sex composition affects fertility behavior and also reveals that preference for sons persists in urban Uttar Pradesh. These results underscore the importance of programs and policies that work to enhance the value of girl children.