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Nacht CL, Contreras J, Ehlenbach M, McGregory K, Houser L, Allen BJ. Long-Acting but Reversible: Opportunities to Address Provider Bias in Contraceptive Care. Hosp Pediatr 2024; 14:690-699. [PMID: 39005135 DOI: 10.1542/hpeds.2023-007673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/09/2024] [Indexed: 07/16/2024]
Abstract
Jasmine is an 18-year-old Black female bringing her infant to the pediatrician for a newborn weight check. She asks her pediatrician's opinion about hormonal contraceptive injections, sharing that they were strongly recommended after she gave birth. The recommending health care provider told her, "We don't want you to end up back here any time soon." Rosita, a 16-year-old Latina female, visits her pediatrician for a well check. She reports a history of vaginal sex with 2 male partners and agrees to have a hormonal subcutaneous implant placed to avoid pregnancy. After 4 months of bothersome spotting, Rosita returns to have the implant removed. Rosita's provider strongly counsels against removal. Jasmine and Rosita are members of populations that have been systematically marginalized throughout American history. Their stories are derived from real cases and reveal how structural racism impacts modern contraceptive care. Specifically, their cases are examples of statistical discrimination, wherein the tendency to disproportionately recommend long-acting reversible contraception to historically marginalized communities does not follow the central tenants of sexual and reproductive justice, including acknowledging historical harms in health care and honoring bodily autonomy for all people. By sharing Jasmine and Rosita's stories, we use a reproductive justice lens to (1) examine the historical roots of disproportional prescription of long-acting reversible contraception to historically marginalized individuals, (2) discuss provider bias related to sexual and reproductive health care, and (3) illustrate how trauma-informed care with a recognition of historical trauma and the use of individuation can facilitate positive and equitable health outcomes.
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Affiliation(s)
- Carrie L Nacht
- School of Public Health, San Diego State University, San Diego, California
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California
| | - Jenna Contreras
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mary Ehlenbach
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kelly McGregory
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Laura Houser
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brittany J Allen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Rothschild CW, Bulama A, Odeh R, Chika-Igbokwe S, Njogu J, Tumlinson K, Musau A. Preference-aligned fertility management among married adolescent girls in Northern Nigeria: assessing a new measure of contraceptive autonomy. BMJ Glob Health 2024; 9:e013902. [PMID: 38760023 PMCID: PMC11103226 DOI: 10.1136/bmjgh-2023-013902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 04/24/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION Universal access to sexual and reproductive healthcare-including family planning (FP)-is a global priority, yet there is no standard outcome measure to evaluate rights-based FP programme performance at the regional, national or global levels. METHODS We collected a modified version of preference-aligned fertility management (PFM), a newly proposed rights-based FP outcome measure which we operationalised as concordance between an individual's desired and actual current contraceptive use. We also constructed a modified version (satisfaction-adjusted PFM) that reclassified current contraceptive users who wanted to use contraception but who were dissatisfied with their method as not having PFM. Our analysis used data collected 3.5 months after contraceptive method initiation within an ongoing prospective cohort of married adolescent girls aged 15-19 years in Northern Nigeria. We described and compared prevalence of contraceptive use and PFM in this population. RESULTS Ninety-seven per cent (n=1020/1056) of respondents were practising PFM 3.5 months after initiating modern contraception, while 93% (n=986/1056) were practising satisfaction-adjusted PFM. Among participants not practising satisfaction-adjusted PFM (n=70), most were using contraception but did not want to be (n=30/70, 43%) or wanted to use contraception but were dissatisfied with their method (n=34/70, 49%), while the remaining 9% (n=6/70) wanted but were not currently using contraception. CONCLUSION PFM captured meaningful discordance between contraceptive use desires and behaviours in this cohort of married Nigerian adolescent girls. Observed discordance in both directions provides actionable insights for intervention. PFM is a promising rights-focused FP outcome measure that warrants future field-testing in programmatic and population-based research.
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Affiliation(s)
- Claire W Rothschild
- Sexual and Reproductive Health, Population Services International, Washington, District of Columbia, USA
| | | | - Roselyn Odeh
- Society for Family Health Nigeria, Abuja, Nigeria
| | | | - Julius Njogu
- Sexual and Reproductive Health, Population Services International, Nairobi, Kenya
| | - Katherine Tumlinson
- University of North Carolina, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Abednego Musau
- Sexual and Reproductive Health, Population Services International, Nairobi, Kenya
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Harrington EK, Hauber B, Ouma DC, Kimanthi S, Dollah A, Onono M, Bukusi EA. Priorities for contraceptive method and service delivery attributes among adolescent girls and young women in Kenya: a qualitative study. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1360390. [PMID: 38774834 PMCID: PMC11107089 DOI: 10.3389/frph.2024.1360390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/08/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction Despite increasing global commitment to meeting the family planning needs of adolescent girls and young women (AGYW), there is limited research on how they prioritize contraceptive method and service delivery characteristics. In this qualitative study, we examine the specific elements that drive the contraceptive choices of Kenyan AGYW, and apply our findings to the development of attributes and levels for a discrete choice experiment (DCE). Methods Our four-stage approach included data collection, data reduction, removing inappropriate attributes, and optimizing wording. Between June-October 2021, we conducted in-depth interviews with 30 sexually-active 15-24 year-old AGYW in Kisumu county, Kenya who were non-pregnant and desired to delay pregnancy. Interviews focused on priorities for contraceptive attributes, how AGYW make trade-offs between among these attributes, and the influences of preferences on contraceptive choice. Translated transcripts were qualitatively coded and analyzed with a constant comparative approach to identify key concepts. We developed and iteratively revised a list of attributes and levels, and pre-tested draft DCE choice tasks using cognitive interviews with an additional 15 AGYW to optimize comprehension and relevance. Results In-depth interview participants' median age was 18, 70% were current students, and 93% had a primary sexual partner. AGYW named a variety of priorities and preferences related to choosing and accessing contraceptive methods, which we distilled into six key themes: side effects; effectiveness; user control; privacy; source of services; and cost. Bleeding pattern was top of mind for participants; amenorrhea was generally considered an intolerable side effect. Many participants felt more strongly about privacy than effectiveness, though some prioritized duration of use and minimizing chance of pregnancy above other contraceptive characteristics. Most AGYW preferred a clinic setting for access, as they desired contraceptive counseling from a provider, but pharmacies were considered preferable for reasons of privacy. We selected, refined, and pre-tested 7 DCE attributes, each with 2-4 levels. Conclusions Identifying AGYW preferences for contraceptive method and service delivery characteristics is essential to developing innovative strategies to meet their unique SRH needs. DCE methods may provide valuable quantitative perspectives to guide and tailor contraceptive counseling and service delivery interventions for AGYW who want to use contraception.
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Affiliation(s)
- Elizabeth K. Harrington
- Department of OB/GYN, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Brett Hauber
- School of Pharmacy, Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, United States
- Pfizer, Inc., New York, NY, United States
| | - Dismas Congo Ouma
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Syovata Kimanthi
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Maricianah Onono
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A. Bukusi
- Department of OB/GYN, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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Abiyo J, Nabirye RC, Nambozo B, Mukunya D, Nantale R, Oguttu F, Wani S, Musaba MW, Tumuhamye J, Epuitai J. "I have come to remove it because of heavy bleeding": a mixed-methods study on early contraceptive implant removal and the underlying factors in eastern Uganda. Contracept Reprod Med 2024; 9:17. [PMID: 38627845 PMCID: PMC11020533 DOI: 10.1186/s40834-024-00279-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/29/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Early contraceptive implant removal without intentions to conceive predisposes women to unintended pregnancies.. Some of the unintended pregnancies end in unsafe abortions which further increases the risk of maternal mortality and morbidity. Therefore, we assessed the proportion of women who had early contraceptive implant removal. We also explored the reasons for early contraceptive implant removalamong women at Mbale Regional Referral Hospital in eastern Uganda. METHODS We conducted a sequential explanatory mixed methods study at Mbale Regional Referral Hospital between November 2022 to December 2022. For quantitative data, we performed a secondary analysis on data extracted from the integrated family planning registers. We used systematic random sampling to select 600 clients' serial numbers from the registers. The outcome variable was early contraceptive implant removal defined as removal of the implant by the woman before 18 months from the time of insertion. For qualitative data, we conducted 11 in-depth interviews among women who had come for contraceptive implant removal at the family planning clinic. We also conducted two key informant interviews with midwives working at the family planning unit. Quantitative data were analysed using Stata version 14.0 (Stata Corp LLC, College Station, Texas, USA) while qualitative data were analysed by thematic content analysis. RESULTS In this study, 15% (91/600) of the women discontinued contraceptive implants within 12 months, 29% (175/600) within 18 months, 38% (230/600) within 24 months and 40% (240/600) within 36 months of insertion. Among the women who discontinued contraceptive implant use, only 6.7% (40/600) switched to another family planning method. Out of the 175 women who removed contraceptive implants early, side effects 61.1% (107/175) desire to conceive 53.1% ( 93/175),, and gender-based violence 8.6% (15/175) were the major reasons for removal. From the qualitative interviews, the major reasons for early contraceptive implant removal were side effects such as heavy menstrualbleeding. CONCLUSION A third of women discontinued contraceptive implant use within 18 months. Addressing concerns regarding side effects and male partner disapproval of modern contraceptives may improve continued use of implants.
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Affiliation(s)
- Janet Abiyo
- Department of Nursing, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Rose Chalo Nabirye
- Department of Nursing, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Brendah Nambozo
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda.
| | - David Mukunya
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Ritah Nantale
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Faith Oguttu
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Solomon Wani
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Milton W Musaba
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
- Busitema University Centre of Excellency for Maternal Reproductive and Child Health, Mbale, Uganda
| | - Josephine Tumuhamye
- Makerere University Hospital, Makerere University Kampala, Kampala, P.O.BOX 7062, Uganda
| | - Joshua Epuitai
- Department of Nursing, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
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Wollum A, Moucheraud C, Sabasaba A, Gipson JD. Removal of long-acting reversible contraceptive methods and quality of care in Dar es Salaam, Tanzania: Client and provider perspectives from a secondary analysis of cross-sectional survey data from a randomized controlled trial. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002810. [PMID: 38261598 PMCID: PMC10805313 DOI: 10.1371/journal.pgph.0002810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024]
Abstract
Access to removal of long-acting reversible contraception (LARCs) (e.g., implants and intrauterine devices (IUDs)) is an essential part of contraceptive care. We conducted a secondary analysis of cross-sectional survey data from a randomized controlled trial. We analyzed 5,930 client surveys and 259 provider surveys from 73 public sector facilities in Tanzania to examine the receipt of desired LARC removal services among clients and the association between receipt of desired LARC removal and person-centered care. We used provider survey data to contextualize these findings, describing provider attitudes and training related to LARC removals. All facilities took part in a larger randomized controlled trial to assess the Beyond Bias intervention, a provider-focused intervention to reduce provider bias on the basis of age, marital status, and parity. Thirteen percent of clients did not receive a desired LARC removal during their visit. Clients who were young, had lower perceived socioeconomic status, and visited facilities that did not take part in the Beyond Bias intervention were less likely to receive a desired removal. Clients who received a desired LARC removal reported higher levels of person-centered care (β = .07, CI: .02 - .11, p = < .01). Half of providers reported not being comfortable removing a LARC before its expiration (51%) or if they disagreed with the client's decision (49%). Attention is needed to ensure clients can get their LARCs removed when they want to ensure patient-centered care and protect client autonomy and rights. Interventions like the Beyond Bias intervention, may work to address provider-imposed barriers to LARC removals.
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Affiliation(s)
- Alexandra Wollum
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States of America
- The UCLA Bixby Center on Population and Reproductive Health, Los Angeles, California, United States of America
| | - Corrina Moucheraud
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York City, New York, United States of America
| | - Amon Sabasaba
- Health for a Prosperous Nation (H-PON), Dar es Salaam, Tanzania
| | - Jessica D. Gipson
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States of America
- The UCLA Bixby Center on Population and Reproductive Health, Los Angeles, California, United States of America
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Sokol NA, Sawadogo N, Bullington BW, Tumlinson K, Langer A, Soura A, Zabre P, Sie A, Johnson JA, Senderowicz L. Perceptions of access to long-acting reversible contraception removal among women in Burkina Faso. Contraception 2024; 129:110302. [PMID: 37802461 PMCID: PMC11285006 DOI: 10.1016/j.contraception.2023.110302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVES Long-acting reversible contraception (LARC) initiation has been well-studied and intervened upon. Because LARC requires provider intervention for initiation and removal, it is critical to measure informed choice at the time of desired discontinuation as well. We examined perceptions of access to LARC discontinuation among women at two sites in Burkina Faso, where LARC is the dominant method in the contraceptive mix. STUDY DESIGN We analyzed data from a 2017-2018 population-based, cross-sectional survey of 281 implant users and 55 intrauterine device users at two sites in Burkina Faso. We measured perceptions of access to LARC discontinuation through survey items assessing whether participants (1) were informed on how to discontinue the method, (2) believed they could have LARC removed without a lot of difficulty, (3) believed cost would be a barrier to discontinuation, (4) had ever attempted to have a provider remove LARC, and (5) successfully had LARC removed. The distribution of these measures was examined in the population and for differences by gravida, parity, domestic partnership, fertility desires, and recency of last childbirth. RESULTS Thirty-eight (11%) of current LARC users reported that they were not informed on how to discontinue, 56 (17%) believed having their device removed would be difficult, and 54 (16%) believed cost would be a barrier to removal. Of women who attempted removal, providers did not immediately remove LARC on request for 10 (28%). CONCLUSIONS Findings indicate that LARC uptake is an insufficient measure of reproductive access or choice. Future studies should include patient-centered measures that span the full duration of contraceptive use. IMPLICATIONS This paper finds that a sizable proportion of LARC users lack information about method discontinuation and perceive or experience barriers to method removal. These findings call for a reconsideration of free and informed contraceptive choice to include the entire duration of contraceptive use, not only the time of method provision.
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Affiliation(s)
- Natasha A Sokol
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States; Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, United States.
| | - Nathalie Sawadogo
- Institut Supérieur des Sciences de la Population, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | - Brooke W Bullington
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Katherine Tumlinson
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States; Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States
| | - Ana Langer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Abdramane Soura
- Institut Supérieur des Sciences de la Population, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | - Pascal Zabre
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ali Sie
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Janet A Johnson
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, United States
| | - Leigh Senderowicz
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States; Department of Gender and Women's Studies, University of Wisconsin-Madison, Madison, Wisconsin, United States; Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, Wisconsin, United States
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DiCenzo N, Brandi K, Getz K, Matthews G. Characteristics Associated With Physician Bias in Contraceptive Recommendations. Womens Health Issues 2024; 34:51-58. [PMID: 37741718 DOI: 10.1016/j.whi.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE We aimed to examine associations between obstetrician-gynecologist (OBGYN) contraceptive recommendations and sociodemographic characteristics of patients and recommending physicians. METHODS OBGYNs affiliated with residency programs across the United States were recruited via email to participate in an online exploratory survey depicting scenarios of reproductive-age women of differing race and socioeconomic status, all other factors identical, and were asked to provide contraceptive recommendations. The χ2 test, Fisher's exact tests, and logistic regression were used to analyze recommendation differences based on physician and patient characteristics. RESULTS Of 172 physician respondents, large proportions self-identified as white (74%) and attending physicians (56%) from the Mid-Atlantic (42%). In multivariate logistic regression, self-administered methods (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.2-0.8) and condoms (OR, 0.5; 95% CI, 0.3-0.9) were recommended significantly less to Black high SES patients compared with white high SES patients. Non-white physicians recommended tubal ligation (OR, 0.7; 95% confidence interval [CI], 0.5-0.9) significantly less than white physicians, and recommended long-acting reversible contraception (OR, 3.3, CI 2.2-5.2) and condoms (OR, 1.4; 95% CI, 1.1-1.9) significantly more. Trainee physicians recommended self-administered methods (OR, 0.3; 95% CI, 0.2-0.4), condoms (OR, 0.2; 95% CI, 0.2-0.3), and tubal ligation (OR, 0.4; 95% CI, 0.3-0.6) significantly less than attending physicians. CONCLUSIONS OBGYN contraceptive recommendations differed based on patients' perceived race and SES. Recommendations also differed based on race, training level, and geographic location of the recommending physician. Results suggest that physician bias contributes to contraceptive recommendations. OBGYNs should receive education about contraceptive coercion and patient-centered decision-making so that they provide high-quality counseling to all patients.
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Affiliation(s)
- Natalie DiCenzo
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| | - Kristyn Brandi
- American College of Obstetricians and Gynecologists, Washington, District of Columbia
| | - Kylie Getz
- Department of Public Health and Biostatistics, Rutgers University, New Brunswick, New Jersey
| | - Glenmarie Matthews
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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8
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DiCenzo N, Gill P, Brandi K. Who gets to decide? Assessing contraceptive coercion in health care settings. Health Serv Res 2023; 58:767-771. [PMID: 37347540 PMCID: PMC10315370 DOI: 10.1111/1475-6773.14193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
See related article by Swan et al .
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Affiliation(s)
- Natalie DiCenzo
- Rutgers Robert Wood Johnson Medical School, Department of Obstetrics and GynecologyNew BrunswickNew JerseyUSA
| | - Puneet Gill
- New York Institute of Technology College of Osteopathic MedicineGlen HeadNew YorkUSA
| | - Kristyn Brandi
- American College of Obstetricians and GynecologistsWashingtonDCUSA
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Tumlinson K, Senderowicz L, Bullington BW, Chung S, Goland E, Zimmerman L, Gichangi P, Thiongo M, Guiella G, Karp C. Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study. BMJ Open 2023; 13:e071775. [PMID: 37463804 PMCID: PMC10357675 DOI: 10.1136/bmjopen-2023-071775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal. METHODS We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred. FINDINGS The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day. CONCLUSION Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals.
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Affiliation(s)
- Katherine Tumlinson
- Department of Maternal and Child Health, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Leigh Senderowicz
- Departments of Gender and Women's Studies, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Brooke W Bullington
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephanie Chung
- Department of Maternal and Child Health, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emilia Goland
- Department of Maternal and Child Health, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Linnea Zimmerman
- Department of Population, Family & Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Peter Gichangi
- International Centre for Reproductive Health-Kenya, Nairobi, Kenya
| | - Mary Thiongo
- International Centre for Reproductive Health-Kenya, Nairobi, Kenya
| | | | - Celia Karp
- Department of Population, Family & Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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10
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Marston C, Tabot M. How can we put rights at the core of global family planning? Lancet 2023; 401:2096-2098. [PMID: 37003288 DOI: 10.1016/s0140-6736(23)00523-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 04/03/2023]
Affiliation(s)
- Cicely Marston
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
| | - Mallah Tabot
- International Planned Parenthood Federation, Africa Regional Office, Nairobi, Kenya
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11
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Bullington BW, Sawadogo N, Tumlinson K, Langer A, Soura A, Zabre P, Sié A, Senderowicz L. Exploring Upward and Downward Provider Biases in Family Planning: The Case of Parity. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200470. [PMID: 37348946 PMCID: PMC10285731 DOI: 10.9745/ghsp-d-22-00470] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Provider bias has become an important topic of family planning research over the past several decades. Much existing research on provider bias has focused on the ways providers restrict access to contraception. Here, we propose a distinction between the classical "downward" provider bias that discourages contraceptive use and a new conception of "upward" provider bias that occurs when providers pressure or encourage clients to adopt contraception. METHODS Using cross-sectional data from reproductive-aged women in Burkina Faso, we describe lifetime prevalence of experiencing provider encouragement to use contraception due to provider perceptions of high parity (a type of upward provider bias) and provider discouragement from using contraception due to provider perceptions of low parity (a type of downward provider bias). We also examine associations between sociodemographic characteristics and experiences of provider encouragement to use contraception due to perceptions of high parity. RESULTS Sixteen percent of participants reported that a provider had encouraged them to use contraception due to provider perceptions of high parity, and 1% of participants reported that a provider had discouraged them from using contraception because of provider perceptions of low parity. Being married, being from the rural site, having higher parity, and having attended the 45th-day postpartum check-up were associated with increased odds of being encouraged to use contraception due to provider perceptions of high parity. CONCLUSION We find that experiences of upward provider bias linked to provider perceptions of high parity were considerably more common in this setting than downward provider bias linked to perceptions of low parity. Research into the mechanisms through which upward provider bias operates and how it may be mitigated is imperative to promote contraceptive autonomy.
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Affiliation(s)
- Brooke W Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nathalie Sawadogo
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Ouagadougo, Burkina Faso
| | - Katherine Tumlinson
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Maternal Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ana Langer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Abdramane Soura
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Ouagadougo, Burkina Faso
| | - Pascal Zabre
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Leigh Senderowicz
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Gender and Women's Studies, University of Wisconsin-Madison, Madison, WI, USA
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, USA
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Senderowicz L, Bullington BW, Sawadogo N, Tumlinson K, Langer A, Soura A, Zabré P, Sié A. Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator. Stud Fam Plann 2023; 54:201-230. [PMID: 36729070 PMCID: PMC10184300 DOI: 10.1111/sifp.12224] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is growing consensus in the family planning community around the need for novel measures of autonomy. Existing literature highlights the tension between efforts to pursue contraceptive targets and maximize uptake on the one hand, and efforts to promote quality, person-centeredness, and contraceptive autonomy on the other hand. Here, we pilot a novel measure of contraceptive autonomy, measuring it at two Health and Demographic Surveillance System sites in Burkina Faso. We conducted a population-based survey with 3,929 women of reproductive age, testing an array of new survey items within the three subdomains of informed choice, full choice, and free choice. In addition to providing tentative estimates of the prevalence of contraceptive autonomy and its subdomains in our sample of Burkinabè women, we critically examine which parts of the proposed methodology worked well, what challenges/limitations we encountered, and what next steps might be for refining, improving, and validating the indicator. We demonstrate that contraceptive autonomy can be measured at the population level but a number of complex measurement challenges remain. Rather than a final validated tool, we consider this a step on a long road toward a more person-centered measurement agenda for the global family planning community.
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Affiliation(s)
- Leigh Senderowicz
- Department of Gender and Women's Studies, University of Wisconsin-Madison, Madison, WI, USA
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brooke W Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nathalie Sawadogo
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Ouagadougou, Burkina Faso
| | - Katherine Tumlinson
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ana Langer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Abdramane Soura
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Ouagadougou, Burkina Faso
| | - Pascal Zabré
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
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Senderowicz L, Sokol N, Pearson E, Francis J, Ulenga N, Bärnighausen T. The effect of a postpartum intrauterine device programme on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial. Health Policy Plan 2022; 38:38-48. [PMID: 36330537 PMCID: PMC9849716 DOI: 10.1093/heapol/czac094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 10/14/2022] [Accepted: 11/08/2022] [Indexed: 11/06/2022] Open
Abstract
Vertical global health programmes often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum intrauterine device (PPIUD) intervention on outcomes related to contraceptive method choice. The stepped-wedge cluster randomized contolled trial (RCT) took place in five Tanzanian hospitals. Hospitals were randomized to receive immediate (Group 1; n = 11 483 participants) or delayed (Group 2; n = 8148 participants) intervention. The intervention trained providers on PPIUD insertion and counselling. The evaluation surveyed eligible women (18+, resided in Tanzania, gave birth at a study hospital) on provider postpartum contraceptive counselling during pregnancy or immediately postpartum. In our completed study, participants were considered exposed (n = 9786) or unexposed (n = 10 145) to the intervention based on the location and timing of their birth (no blinding). Our secondary analysis examined differences by intervention exposure on the likelihood of being counselled on IUD only, multiple methods, multiple method durations, a broad method mix; and on the number of methods women were counselled across two samples: all eligible women, and only women who reported receiving any contraceptive counselling. Among all eligible women, counselling on the IUD alone was 7% points higher among the exposed (95% confidence interal (CI): 0.02, 0.12). Among women who received any counselling, those exposed to the intervention were counselled on 1.12 fewer contraceptive methods (95% CI: 0.10, 2.34). The likelihood of receiving counselling on any non-IUD method decreased among those exposed, while the likelihood of being counselled on an IUD alone was 14% points higher among the exposed (95% CI: 0.06, 0.22), suggesting this intervention increased IUD-specific counselling but reduced informed contraceptive choice. These findings underscore the importance of broad metrics that capture autonomy and rights (in addition to programmatic goals) at all stages of health programme planning and implementation.
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Affiliation(s)
- Leigh Senderowicz
- *Corresponding author. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave., Boston, MA 02115, USA. E-mail:
| | - Natasha Sokol
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, School of Public Health, Brown University, 121 South Main St., Providence, RI 02903, USA
| | - Erin Pearson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave., Boston, MA 02115, USA,Department of Technical Excellence, Ipas, P.O. Box 9990, Chapel Hill, NC 27515, USA
| | - Joel Francis
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 29 Princess of Wales Terrace, Parktown, Johannesburg 2193, South Africa,Management and Development for Health, P.O Box 79810. Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, P.O Box 79810. Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave., Boston, MA 02115, USA,Heidelberg Institute of Global Health (HIGH), University of Heidelberg, Im Neuenheimer Feld 130.3. Marsilius Arkaden—6. Stock, Heidelberg 69120, Germany
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