Lessons from the recent rise in use of female sterilization in Malawi

Health care and contraceptive decision-making autonomy and use of female sterilisation among married women in Malawi

Introduction

Female sterilisation is the most common contraceptive method used globally. The use of female sterilisation is disproportionately low in sub-Sahara Africa (SSA) at just 1%. Nonetheless, the prevalence of sterilisation among married women in Malawi is quite high at about 11%. While a few recent studies in SSA have examined the relationship between women's decision-making autonomy and use of long-acting contraceptives, very few have investigated whether different dimensions of decision-making autonomy predict the use of female sterilisation differently. The objective of this study was therefore to examine the relationship between health care and contraceptive decision-making autonomy and the use of female sterilisation in Malawi.

Data and methods

The study relied on secondary data from the 2015-16 Malawi Demographic and Health Survey. The sample comprised 9,164 married women in Malawi that were using a modern contraceptive. Multinomial logistic regression analysis was used to examine the association between health care and contraceptive decision-making autonomy and the use of female sterilisation, controlling for key socio-demographic characteristics.

Results

The study revealed that the percentage of married women that made health care and contraceptive decisions independently was quite low. The main finding of this study was that contraceptive decision-making autonomy increased the relative likelihood of using female sterilisation while health care autonomy was associated with a lower likelihood of being sterilized. The socio- demographic characteristics that significantly predicted the use of female sterilisation included age, place of residence, household wealth and the number of children a woman had.

Conclusion

This study demonstrates that health care and contraceptive decision making have different effects on the use of female sterilisation among married women in Malawi. Specifically, women with autonomy in health care decision making had a relatively lower likelihood of using female sterilisation while those with contraceptive decision-making autonomy had a higher likelihood of using female sterilisation. This suggests that intervention aimed at increasing the uptake of female sterilisation in Malawi need to focus on empowering women in the contraceptive decision-making domain.

The demand for family planning to limit childbearing satisfied with female permanent contraception in Sub-Saharan Africa: a meta-analysis of demographic and health surveys

OBJECTIVE

To assess the percentage of the demand for family planning to limit childbearing satisfied with female permanent contraception (FPC) in sub-Saharan Africa (SSA) and the disparities by sociodemographic characteristics (educational status, wealth, religion, and area of residence).

STUDY DESIGN

This study was a secondary data analysis of Demographic and Health Surveys conducted in SSA. Countries with a standard DHS conducted between 2010 and 2019 were eligible for inclusion. We performed a meta-analysis with a random-effects model to estimate the percentage of the demand for family planning to limit childbearing satisfied with FPC and differences by sociodemographic characteristics.

RESULTS

Demographic and Health Surveys (2010-2018) of 33 countries, with a total of 67,476 women with a demand for family planning to limit childbearing were included in this study. The pooled percentage of the demand for family planning to limit childbearing satisfied with FPC was 4.13% (95%CI = 2.43-6.23%, I = 99.36%, p = 0.001). The percentage ranged from 0.26% (95%CI = 0.10-0.67) in Angola to 26.85% (95%CI = 25.86-27.85%) in Malawi. The demand for family planning to limit childbearing satisfied with FPC was significantly higher in women from rich households (PR = 1.41, 95%CI = 1.21-1.65, p < 0.001). However, the differences by educational status, religion, or area of residence were not statistically significant.

CONCLUSIONS

The uptake of FPC among women with a demand for family planning to limit childbearing is low in many countries in SSA. Multilevel interventions are needed to address the barriers that may be limiting informed and voluntary uptake of FPC in SSA.

Individual- and country-level correlates of female permanent contraception use in sub-Saharan Africa

Background

Female permanent contraception is a cost-effective contraceptive method that can help clients with the desire to limit childbearing achieve their reproductive intention. However, despite its benefits, the use of FPC remains low in sub-Saharan Africa (SSA), and limited studies have examined the correlates of its uptake. In this study, we assessed the individual- and country-level factors associated with the use of FPC among married or in-union women using modern contraceptive methods to limit childbearing in SSA.

Methods

This study was a secondary data analysis of individual- and country-level data obtained from the Demographic and Health Surveys (DHS) Program and three open data repositories. The study included 29,777 married or in-union women aged 15–49 years using modern contraceptive methods to limit childbearing from DHS conducted in 33 sub-Sahara African countries between 2010 and 2018. We performed descriptive statistics and fitted multilevel logistic regression models to determine the predisposing, enabling, and need factors associated with the use of FPC.

Results

Approximately 13% of the women used FPC. About 20% of the variance in the odds of using FPC was attributable to between-country differences. In the full model, the significant individual-level factors associated with the use of FPC compared with other modern contraceptive methods were: age (odds ratio [OR] = 1.10; 95%CI = 1.08–1.12), living children (OR = 1.11, 95%CI = 1.04–1.16), high household wealth (OR = 1.39, 95%CI = 1.18–1.64), rural residence (OR = 0.83, 95% CI = 0.71–0.97), joint contraceptive decision with partner (OR = 1.68, 95% = 1.43–1.99), contraceptive decision by partner and others (OR = 2.46, 95% = 1.97–3.07), and the number of living children less than the ideal number of children (OR = 1.40, 95%CI = 1.21–1.62). The significantly associated country-level factors were births attended by skilled health providers (OR = 1.03, 95%CI = 1.00–1.05) and density of medical doctors (OR = 1.37, 95%CI = 1.01–1.85).

Conclusions

Our results suggest that both individual- and country-level factors affect uptake of FPC in SSA. Increasing geographic, economic, and psychosocial access to FPC may improve its uptake in SSA.

Bring back the tubal: An intervention to provide postpartum tubal ligation in the underserved population

We aimed to improve educational awareness of postpartum bilateral tubal ligation (PPBTL), which we defined as a 15% improvement between pre-/post-intervention questionnaire scores. We followed patients desiring and undergoing PPBTL and reason for unfulfilled procedures from 2017-2018. OB/GYN, Nursing, and Anesthesia participated in educational sessions with pre-/post-intervention questionnaires. Comparing the first and latter six months after study initiation, PPBTLs performed increased from 39% to 54%. Fifty-two staff participated in the interventions, with a 21% improvement in scores (OB/GYN p = 0.0117, Nursing p = 0.0001, Anesthesia p = 0.0002). We conclude multidisciplinary interventions improved educational awareness, an integral part to increasing PPBTL performance in the underserved.

Long-Acting Reversible Contraception Uptake and Associated Factors among Women of Reproductive Age in Rural Kenya

In the last two decades, the use of short-acting methods of contraception has driven the increase of contraceptive use in Kenya. We assessed the factors associated with uptake of long-acting reversible contraception by women seeking family planning services in public health facilities in Kakamega County, Kenya. A mixed methods cross-sectional study through client exit surveys among 423 women seeking family planning services was done at 12 public health facilities in Kakamega County. Twelve in-depth interviews with health care providers from the study facilities further explored practices in provision of long-acting reversible contraception (LARC). Among women initiating contraceptive use, LARC method utilization was 20.6%. Women's tertiary education level, Protestant Christian religion, age at first birth, and having no desire for more children were significantly associated with utilization of LARC. Structural factors including shortage of human resource, provider bias and lack of adequate skills on provision of services were identified as key barriers to uptake of long-acting reversible contraception services.

Uptake of permanent contraception among women in sub-Saharan Africa: a literature review of barriers and facilitators

OBJECTIVE

Uptake of permanent contraception among women remains low in sub-Saharan Africa compared to other regions. We aimed to synthesize available evidence on barriers to, and facilitators of permanent contraception with regards to tubal ligation among women in sub-Saharan Africa.

STUDY DESIGN

We reviewed literature on tubal ligation among African women published between January 1, 2000 and October 30, 2017. We searched PubMed, Global health, EMBASE, Web of science, and Google scholar for quantitative, qualitative, and mixed methods studies which reported on barriers and/or facilitators to uptake of tubal ligation in sub-Saharan Africa. Finally, we conducted a narrative synthesis and categorized our findings using a framework based on the social ecological model.

RESULTS

We included 48 articles in the review. Identified barriers to tubal ligation among women included individual-level (myths and misconceptions, fear of surgery, irreversibility of procedure, religious beliefs), interpersonal-level (male partner disapproval), and organizational-level (lack of healthcare worker expertise and equipment) factors. Facilitating factors included achievement of desired family size and perceived effectiveness (individual-level), supportive male partners and knowing other women with permanent contraception experience (interpersonal-level), and finally, subsidized cost of the procedure and task-sharing with lower cadre healthcare workers (organizational-level).

CONCLUSIONS

Barriers to, and facilitators of permanent contraception among women in sub-Saharan Africa are multilevel in nature. Strategies countering these barriers should be prioritized, as effective contraception can promote women's health and economic development in sub-Saharan Africa. In addition to these strategies, more quantitative research is needed to further understand patient-level factors associated with uptake of permanent contraception among women.

Client Perceptions of Quality and Choice at Static, Mobile Outreach, and Special Family Planning Day Services in 3 African Countries

In all 3 countries, nearly all women obtained their method of choice, with more mobile outreach and special family planning day clients having a preexisting preference for implants than static service clients. Clients of all service modalities in all countries reported experiencing most elements of full, free, and informed choice, but there is room for improvement with some aspects, such as counseling about potential side effects and giving clients the opportunity to ask questions.

Background:

Use of long-acting reversible contraceptives (LARCs) has grown rapidly in the Democratic Republic of the Congo (DRC), Tanzania, and Uganda. Uptake of LARCs is particularly high during mobile outreach and special family planning day events. It is therefore important to examine client perceptions of and experiences with full, free, and informed choice (FFIC) in different service delivery modalities.

Methods:

Between April and July 2015, we conducted a cross-sectional family planning client survey to assess FFIC and client satisfaction at static, mobile outreach, and special family planning day services in the DRC (n=9 sites), Tanzania (n=13), and Uganda (n=8). The study investigated clients' perceptions across 13 elements of FFIC, including measures of the quality of counseling and respondent satisfaction with services across the service delivery approaches. Composite FFIC scores were constructed and analyzed as the proportion of women who reported affirmatively to all elements and the mean score of positive responses. Satisfaction was assessed using a 4-point Likert scale. We used logistic regression to assess the association between the primary outcomes and mode of service delivery.

Results:

In total, we interviewed 585 women (n=150 in Uganda, n=200 in Tanzania, and n=235 in the DRC). The large majority of clients in all countries and modalities received their method of choice. Clients of mobile outreach and special family planning days preferred LARCs and permanent methods, particularly implants, compared with clients at static services. Composite measures of FFIC were lower for mobile outreach than for static services in Tanzania among all family planning clients (odds ratio [OR]=0.5; P≤.001) and among LARC clients specifically (OR=0.5; P≤.01); no significant differences were found in the DRC or Uganda. A mean FFIC score among all family planning clients showed that clients in all modalities in all countries reported experiencing most elements of FFIC, with averages ranging from 4.8 to 6.1 of 7 elements. Among LARC clients specifically, mean scores ranged from 8.3 to 9.8 of 11 elements. Where greater proportions of clients experienced higher FFIC, greater proportions of clients also tended to report being “very satisfied” with aspects of services and counseling.

Conclusions:

The results underscore that special family planning days and mobile outreach services are important and viable ways to increase women's access to family planning services, notably to LARCs, but further attention to respecting and fulfilling clients' full, free, and informed choice across all service delivery modalities is required.

Factors influencing use of long-acting versus short-acting contraceptive methods among reproductive-age women in a resource-limited setting

Background

Unplanned pregnancy remains a common problem in many resource-limited settings, mostly due to limited access to modern family planning (FP) services. In particular, use of the more effective long-acting reversible contraceptive (LARC) methods (i.e., intrauterine devices and hormonal implants) remains low compared to the short-acting methods (i.e., condoms, hormonal pills, injectable hormones, and spermicides). Among reproductive-age women attending FP and antenatal care clinics in Uganda, we assessed perceptions and practices regarding the use of modern contraceptive methods. We specifically aimed to evaluate factors influencing method selection.

Methods

We performed a mixed-methods cross-sectional study, in which we administered structured interviews to 180 clients, and conducted 4 focus group discussions (FGDs) with 36 clients and 8 in-depth personal qualitative interviews with health service providers. We summarized quantitative data and performed latent content analysis on transcripts from the FGDs and qualitative interviews.

Results

The prevalence of ever use for LARC methods was 23%. Method characteristics (e.g., client control) appeared to drive method selection more often than structural factors (such as method availability) or individual client characteristics (such as knowledge and perceptions). The most common reasons for choosing LARC methods were: longer protection; better child-spacing; and effectiveness. The most common reasons for not choosing LARC methods included requiring a client-controlled method and desiring to conceive in the near future. The most common reasons for choosing short-acting methods were ease of access; lower cost; privacy; perceived fewer side effects; and freedom to stop using a method without involving the health provider. The personal characteristics of clients, which appeared to be important were client knowledge and number of children. The structural factor which appeared to be important was method availability.

Conclusions

Our results suggest that interventions to improve uptake of LARC among reproductive age women in this setting should consider: incorporating desired method-characteristics into LARC methods; targeted promotion and supply of LARC; and increased counselling, sensitization, and education.

Contraceptive method and self-reported HIV status among women in Malawi

OBJECTIVES

We aimed to describe contraceptive methods used by women in Malawi and determine whether contraceptive use differed by self-reported HIV status. Effective contraception is a primary method of preventing mother-to-child transmission of HIV.

STUDY DESIGN

Analysis is based on 12,658 nonpregnant, sexually debuted women ages 15-49 years in the 2010 Malawi Demographic and Health Survey. Analysis was restricted to respondents with contraceptive need (i.e., fecund and did not want a child in the next 12 months) who reported their last HIV test result. We accounted for the two-stage cluster sampling design by applying cluster, stratum and sample weights. We assessed differences in contraceptive method use by HIV status with χ² tests and multivariable logistic regression.

RESULTS

A total of 893 (7.0%) of respondents reported being HIV positive. Use of long-acting reversible contraception (LARC) was low and did not differ between HIV-positive (1.4%) and HIV-negative (1.9%) women [adjusted odds ratio (aOR)=0.7, 95% confidence interval (CI), 0.4-1.4]. HIV-positive women (15.6%) were less likely than HIV-negative women (30.4%) to use progestin-only injectable contraception (aOR, 0.7; 95% CI, 0.5-0.8). Prevalence of female sterilization was higher among HIV-positive women (17.9%) compared to HIV-negative women (9.2%; aOR=1.7; 95% CI, 1.2-2.3).

CONCLUSIONS

LARC use was low among adult women with contraceptive need in Malawi. HIV-positive women were less likely to report progestin-only injectable use but more likely to report having undergone female sterilization compared to their HIV-negative counterparts. Noncoercive interventions that provide highly effective methods of contraception to HIV-positive women with contraceptive need are valuable methods of vertical transmission prevention in Malawi.

IMPLICATIONS

Contraceptive use differed by self-reported HIV status among adult women with contraceptive need in Malawi. Female sterilization was significantly higher, and use of progestin-only injectables was significantly lower, among HIV-positive women compared to their HIV-negative counterparts. Use of long-acting reversible contraception was low among both HIV-positive and HIV-negative women.

Vasectomy: A Long, Slow Haul to Successful Takeoff

Vasectomy use is plagued by low demand among men. Nevertheless, its compelling advantages make substantial investment worthwhile. On the supply side, a priority is to actively link vasectomy with service delivery approaches for the other highly effective long-acting and permanent clinical methods. Robust demand generation should include messaging specific to vasectomy, but should also draw on broader social and behavior change communication efforts increasingly aimed at engaging men in family planning.

Desire for female sterilization among women wishing to limit births in rural Rakai, Uganda

OBJECTIVE

Uganda has an unmet need for family planning of 34% and a total fertility rate of 6.2. We assessed the desire for female sterilization among sexually active women who wanted to stop childbearing in rural Rakai district, Uganda.

STUDY DESIGN

7192 sexually active women enrolled in a community cohort between 2002 and 2008 were asked about fertility intentions. Those stating that they did not want another child (limiters) were asked whether they would be willing to accept female sterilization, if available. Trends in desire for sterilization were determined by chi-square test for trend, and Modified Poisson regression was used to estimate prevalence rate ratios and 95% confidence intervals of the associations between desire for sterilization and socio-demographic characteristics and HIV status.

RESULTS

From 2002 to 2008, the proportion of limiters dropped (from 47.2% to 43.7%; p<.01). Use of pills and injectables among limiters significantly increased, 38.9% to 50.3% (p<.0001), while use of intrauterine devices and implants declined from 3.3% to 1.7% (p<0.001). The desire for sterilization significantly increased from 54.2% to 63.1% (p<0.0001), and this was consistently higher among the HIV-positive (63.6-70.9%, p<0.01) than HIV-negative women (53.3-61.2%, p<0.0001). Factors significantly associated with the desire for sterilization included higher number of living children (>=3), being HIV-infected and having received HIV counseling and testing.

CONCLUSION

There is latent and growing desire for sterilization in this population. Our findings suggest a need to increase permanent contraception services for women who want to limit childbearing in this setting.

IMPLICATIONS

A large unmet need for permanent female contraception services exists in Uganda. Efforts to increase the method mix by increasing permanent contraception services could reduce fertility rates and undesired births.

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.

The Levonorgestrel Intrauterine System: A Pragmatic View of an Excellent Contraceptive

The levonorgestrel intrauterine system (LNG IUS) has major advantages and could be a “game-changer” in improving contraceptive choice and use. It faces important challenges, however, including: (1) high commodity cost; (2) often-strong provider resistance to IUDs and difficult programmatic requirements; (3) need for demand creation, including assessing if markedly reduced menstrual bleeding is attractive to clients; and (4) the many requirements for introducing any new contraceptive. A good next step would be a well-focused and multifaceted “learning introduction” to assess the LNG IUS’s potential in several low-income countries, with rapid scale-up if results are promising.

Family planning: choices and challenges for developing countries

While slow and uneven progress has been made on maternal health, attaining the 1994 Cairo International Conference on Population and Development (ICPD) goal for achieving universal access to reproductive health remains elusive for many developing countries. Assuring access to sexual and reproductive health services, including integrated family planning services, remains a critical strategy for improving the health and well-being of women and alleviating poverty. Family planning not only prevents maternal, infant, and child deaths, but also empowers women to engage fully in socioeconomic development and provides them with reproductive choices. This paper will discuss the current landscape of contraception in developing countries, including options available to women and couples, as well as the challenges to its provision. Finally, we review suggestions to improve access and promising strategies to ensure all people have universal access to reproductive health options.

Contraceptive implants: providing better choice to meet growing family planning demand

Contraceptive implants are extremely effective, long acting, and suitable for nearly all women—to delay, space, or limit pregnancies—and they are increasingly popular. Now, markedly reduced prices and innovative service delivery models using dedicated non-physician service providers offer a historic opportunity to help satisfy women's growing need for family planning.

Meeting the need for modern contraception: effective solutions to a pressing global challenge

Voluntary family planning is one of the most efficacious and cost-effective means of improving individual health, gender equity, family well-being, and national development. Increasing contraceptive use and reducing unmet need for family planning are central to improving maternal health (UN Millennium Development Goal 5). In less-developed regions of the world, especially Sub-Saharan Africa and South Asia, human and financial resources are limited, modern contraceptive use is relatively low, unmet need for modern contraception is high, and consequently maternal morbidity and mortality are high. However, the international community is showing renewed commitment to family planning, a number of high impact program practices have been identified, and a number of Sub-Saharan African countries (e.g. Ethiopia, Malawi, and Rwanda) have successfully made family planning much more widely and equitably available. The International Federation of Gynecology and Obstetrics (FIGO) has joined with other international and donor organizations in calling for increased funding and more effective programming to improve maternal health and family planning in low-resource countries. Continued engagement by FIGO, its member societies, and its individual members will be helpful in addressing the numerous barriers that impede universal access to modern contraception in low-resource countries.