Do natural methods count? underreporting of natural contraception in urban Burkina Faso

Hormonal and natural contraceptives: a review on efficacy and risks of different methods for an informed choice

The debate about contraception has become increasingly important as more and more people seek safe and effective contraception. More than 1 billion women of reproductive age worldwide need a method of family planning, and wellbeing, socio-economic status, culture, religion and more influence the reasons why a woman may ask for contraception. Different contraceptive methods exist, ranging from 'natural methods' (fertility awareness-based methods - FABMs) to barrier methods and hormonal contraceptives (HCs). Each method works on a different principle, with different effectiveness.FABMs and HCs are usually pitted against each other, although it's difficult to really compare them. FABMs are a valid alternative for women who cannot or do not want to use hormone therapy, although they may have a high failure rate if not used appropriately and require specific training. HCs are commonly used to address various clinical situations, although concerns about their possible side effects are still widespread. However, many data show that the appropriate use of HC has a low rate of adverse events, mainly related to personal predisposition.The aim of this review is to summarize the information on the efficacy and safety of FABMs and HCs to help clinicians and women choose the best contraceptive method for their needs.

Declining fertility and increasing use of traditional methods of family planning: a paradox in Uttar Pradesh, India?

Uttar Pradesh (UP), with more than 220 million people, is the most populous state in India. Despite a high unmet need for modern family planning methods, the state has experienced a substantial decline in fertility. India has also seen a decline during this period which can be attributed to the increased prevalence of modern methods of family planning, particularly female sterilisation, but in UP, the corresponding increase was marginal. At the same time, Traditional Family Planning Methods (TMs) increased significantly in UP in contrast to India, where it was marginal. The trends in UP raise questions about the drivers in fertility decline and question the conventional wisdom that fertility declines are driven by modern methods, and the paper aims to understand this paradox. Fertility trends and family planning practices in UP were analysed using data from different rounds of National Family Health Surveys (NFHS) and the two UP Family Planning Surveys conducted by the UP Technical Support Unit to understand whether the use of TMs played a role in the fertility decline. As per NFHS-4, the prevalence of TM in India (6%) was less than half that of UP (13%). The UP Family Planning Survey in 25 High Priority Districts estimated that 22% of women used TMs. The analysis also suggested that availability and accessibiility of modern contraceptives might have played a role in the increased use of TMs in UP. If there are still couples who make a choice in favour of TMs, they should be well informed about the risks associated with the use of traditional methods as higher failure rate is observed among TMs users.

Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator

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.

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.

Let's Talk About Sex: Improving Measurement of Contraceptive Use in Cross-Sectional Surveys by Accounting for Sexual Activity Recency

Findings suggest that the contraceptive use of unmarried women and those who were not recently sexually active are less likely to be captured in standard measures of current contraceptive use. Incorporating information from questions about contraceptive use at last sex may better capture coital-dependent method use and provide a more accurate assessment of who is protected against an unintended pregnancy at next sex.

Introduction:

Standard measures of contraceptive prevalence have known biases given that they do not reflect sexual activity and true exposure to the risk of an unintended pregnancy. In this study, we aim to understand the extent to which women protect themselves against unintended pregnancy, taking into account exposure to sex, by examining contraceptive use patterns by marital status and recent sexual activity.

Methods:

Data come from population-based surveys of reproductive age women in 9 low-resource settings. We estimated contraceptive prevalence using (1) the standard current contraceptive use measure, (2) a new measure of contraceptive use at last sex, and (3) a comprehensive measure that combines current use and use at last sex. Analyses are stratified by site and examine patterns by marital status only, and by both marital status and sexual activity separately. We then examined method mix by each contraceptive measure.

Results:

Study findings reveal distinct patterns in contraceptive use in relation to marital status and sexual recency across sites. Overall, married women tended to report higher levels of current contraceptive use compared to use at last sex, whereas unmarried women reported higher levels of contraceptive use at last sex. When examining these measures by sexual activity and marital status, results indicate lower levels of contraceptive use among women who had not had sex in the month prior to the survey, for both married and unmarried women. The comprehensive measure of contraceptive use yielded the highest estimates, by design. Method mix varied consistently by contraceptive measure, with current use tending to capture more permanent and long-acting methods and use at last sex more likely to capture short-acting and coital-dependent methods.

Discussion:

These findings have important implications for how the family planning field evaluates unintended pregnancy risk and unmet need for contraception within low-resource settings, given different estimates yield discrepant estimates for who is “at risk.”

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

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

Use of Fertility Awareness-Based Methods for Pregnancy Prevention Among Ghanaian Women: A Nationally Representative Cross-Sectional Survey

Few studies in low- and middle-income countries have examined the use of fertility awareness-based methods (FABMs) for pregnancy prevention. Understanding the prevalence of FABM use among Ghanaian contraceptors and the characteristics and practices of users is essential. Our 2018 nationally representative survey of Ghanaian women included detailed questions on the use of rhythm and Standard Days Method/Cycle Beads (SDM). After considering multimethod use patterns, we estimated likely FABM prevalence among contraceptors, identified characteristics associated with current use of an FABM (vs. current use of a hormonal method/intrauterine device [IUD]), and described how women report using FABMs. At least 18% of contracepting Ghanaian women likely use an FABM, though this may be underreported. Among FABM users, 57% reported current use of an FABM alone; the remainder reported concurrent use of other methods. Women who were older, richer, more educated, and had fewer children had higher odds of current FABM use versus IUD/hormonal method. Although FABM users were more likely than other contraceptors to correctly identify the approximate fertile time, only 50% of FABM users did so correctly. Most (92%) rhythm users were interested in making their method use more effective. While 72% had heard of SDM, less than 25% had heard of various other ways to make the rhythm method more effective. Only 17% of rhythm users had ever discussed the method with a health professional. Rhythm users indicated substantial willingness to track additional biomarkers (e.g., daily temperature or cervical mucus) or to use a phone to enhance the effectiveness of their method, and most indicated no substantial difficulty getting partners to abstain or withdraw on fertile days. A nontrivial proportion of reproductive age Ghanaian women are using an FABM, nearly all of whom are interested in learning how to improve its effectiveness. The family planning field should better address these women's contraceptive needs in commitment to reproductive autonomy and choice.

Pathways to Modern Family Planning: A Longitudinal Study on Social Influence among Men and Women in Benin

Despite improvements in family planning (FP) knowledge and services in West Africa, unmet need for FP continues to grow. Many programs apply a demographically and biologically driven definition of unmet need, overlooking the complex social environment in which fertility and FP decisions are made. This longitudinal, qualitative cohort study captures the changing nature of FP need, attitudes and behaviors, taking into account life context to inform understanding of the complex behavior change process. Purposively sampled, 25 women and 25 men participated in three rounds of in‐depth interviews over 18 months. Analyses used a social network influence lens. Findings suggest alignment of six foundational building blocks operating at individual, couple, services, and social levels is essential to meet FP need. If one block is weak, a person may not achieve met need. Women and men commonly follow five pathways as they seek to fulfill their FP need. Some pathways achieve met need (determined users, quick converters), some do not (side effect avoiders), and some do not lead to consistent FP outcomes (male‐priority decision makers, gender–egalitarian decision makers). Findings clarify the role of social determinants of FP and offer insight into program approaches informed by user typologies and return on program investments.

Contraceptive Method Mix: Updates and Implications

Trends in contraceptive method mix show that dominance of 1 method in the mix remains very common, though countries and regions throughout the world are diverse as to which method is dominant. Our analysis argues for continued concerted efforts of programs to increase contraceptive method choice.

Context:

Improving contraceptive method choice is a goal of international family planning. Method mix—the percentage distribution of total contraceptive use across various methods—reflects both supply (availability of affordable methods) and demand (client preferences). We analyze changes in method mix, regional contrasts, and the relationship of the mix to contraceptive prevalence.

Methods:

We use 789 national surveys from the 1960s through 2019, from 113 developing countries with at least 1 million people and with data on use of 8 contraceptive methods. Two measures assess the “evenness” of the mix: method skew (more than 50% use is by 1 method), and the average deviation (AD) of the 8 methods’ shares from their mean value. Population weighted and unweighted results are compared because they can differ substantially.

Results:

Use of traditional methods has declined but still represents 11% of all use (population weighted) or 17% (unweighted country average). Vasectomy’s share was historically low with the exception of a few countries but is now even lower. The previous trend toward greater overall evenness in the mix has slowed recently. Sub-Saharan Africa shows a hormonal method progression from oral contraceptives to injectables to implants in a substantial number of countries. In some countries with high HIV prevalence, the condom share has increased. The leading method’s share differs by region: female sterilization in Asia (39%) and in Latin America (31%), the pill in the Middle East/North Africa (32%), and the injectable in sub-Saharan Africa (36%). Method skew persists in 30% of countries. “Evenness” of mix is not related to contraceptive prevalence.

Conclusion:

The marked diversity in predominant methods underscores the conclusion that no single method mix is ideal or appropriate everywhere. But that diversity across countries, coupled with the persisting high degree of extreme skewness in many of them, argues for continued concerted efforts for programs to increase method choice.

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

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

Correlates of use of withdrawal for contraception among women in Vietnam

Background

Despite its relatively low effectiveness, withdrawal is a common contraceptive practice. In Vietnam, health concerns about hormonal contraception are strong and account for substantial method discontinuation. Given the paucity of evidence on withdrawal, our objective was to identify correlates of using withdrawal among women not desiring pregnancy.

Methods

We conducted a secondary analysis of data from a cross-sectional study of sexually-active adult women attending a public hospital in Hanoi, who did not desire pregnancy. We enrolled a stratified sample of women using the intrauterine device, combination oral contraception, or neither method. Participants completed a questionnaire on demographics and reproductive history and behaviors. We used multinomial logistic regression to evaluate correlates of using a tier 3 contraception method (without withdrawal) and using withdrawal (alone or with a tier 3 method) compared to the referent category of using a tier 1 or 2 method (without withdrawal).

Results

Of the 489 participants in the analysis, 52.3% reported using tier 1 or 2 method (without withdrawal); 19.8% reported tier 3 contraception (without withdrawal) and 27.9% reported using withdrawal (alone or with a tier 3 method). Compared to those using a tier 1 or 2 method, women using withdrawal had lower odds of reporting that avoiding pregnancy was very important or important to them (aOR, 0.4; 95% CI, 0.3–0.7). Women using withdrawal had higher odds of reporting that their husband/partner refuses to give them money for household expenses, even when he has the money (aOR, 2.8; 95% CI, 1.4–5.6).

Conclusions

Women using withdrawal might have less relationship power than nonusers. They also might rely on the practice because they are more ambivalent about pregnancy.

Reconceptualizing Measurement of Emergency Contraceptive Use: Comparison of Approaches to Estimate the Use of Emergency Contraception

Estimated use of emergency contraception (EC) remains low, and one reason is measurement challenges. The study aims to compare EC use estimates using five approaches. Data come from Performance Monitoring and Accountability 2020 surveys from 10 countries, representative sample surveys of women aged 15 to 49 years. We explore EC use employing the five definitions and calculate absolute differences between a reference definition (percentage of women currently using EC as the most effective method) and each of the subsequent four, including the most inclusive (percentage of women having used EC in the past year). Across the 17 geographies, estimated use varies greatly by definition and EC use employing the most inclusive definition is statistically significantly higher than the reference estimate. Impact of using various definitions is most pronounced among unmarried sexually active women. The conventional definition of EC use likely underestimates the magnitude of EC use, which has unique programmatic implications.

"When you least expect, this happens, it's already growing": Problematizing the definition of unmet need for family planning

Background: Unmet need is an important indicator to understand baselines and set goals for family planning interventions. Women may not fall neatly in categories of met or unmet need for family planning as defined by the demographic and health surveys (DHS). We explore women's experiences of unmet need for family planning and provide empirical examples of how the static, binary DHS definitions of met and unmet need for family planning may be problematic. Methods: Based on Social Cognitive Theory, we conducted elicitation interviews with 16 married young women between the ages of 20 and 24 in Chimaltenango, Guatemala to explore barriers to accessing and using family planning. Half the participants (n=8) were using a modern method of family planning and half (n=8) were not. The current analysis focuses on data that was coded as ambiguous or unclear for unmet need status. Results: We identified framings of ambiguity from the women's narratives that are silenced by the dominant binary of met and unmet need. We show inconsistencies between women's lived experiences of unmet need and how their experiences would likely be represented in DHS questionnaires: 1) successful use of natural methods; 2) the complexity of "wantedness"; 3) conceptualizing met or unmet need as a trajectory; and 4) laughter obscuring clear response. Conclusion: Family planning status is a complex trajectory that the DHS may not accurately capture. As a way to reflect the diversity of women's family planning experiences, we suggest modifying the DHS classifications to incorporate latent met and unmet need as sub-classifications.

The complex relationship between contraception and abortion

The incidence of abortion is determined by the incidence of unwelcome, or unintended, pregnancies and the propensity to terminate rather than take them to term. Exposure to the risk of unintended pregnancy rises as the desired family sizes fall, because fewer years of reproductive life are taken up with desired pregnancies. Increases in contraceptive use over recent decades have reduced the risk of unintended pregnancies, but this effect has been moderated in many regions of the world by increased propensity to terminate such pregnancies. Globally, a large majority of abortions are still the direct consequence of non-use of any contraceptive precautions among women or couples not wishing to conceive. Reasons for non-use vary but side effects and health concerns figure prominently. As overall contraceptive use increases, choice of methods becomes a more important influence on the likelihood of unintended pregnancies and abortions. Sterilization, implants and IUDs are more effective at pregnancy-prevention than methods requiring skill, discipline, memory and frequent re-supply. Effective promotion of these methods, however, is difficult once other methods have become entrenched.

Reporting sterilization as a current contraceptive method among sterilized women: lessons learned from a population with high sterilization rates, Rajasthan, India

Objective

Measuring current use of contraception relies on self-reported responses from survey respondents. Reporting validity may be affected by women's interpretation of the question and may vary by background characteristics of women. The study aims to understand levels and patterns of underreporting of female sterilization in a population with high sterilization rates.

Study design

Data came from the Performance Monitoring and Accountability 2020 survey conducted in Rajasthan, India, in early 2017. In addition to a conventional question to ascertain current contraceptive use, the survey included a probing question; women who did not report sterilization as a current method were asked if they were ever sterilized. Women were defined as sterilization users based on either question. Among sterilized women, we estimated the percent who reported sterilization as a current method. Multivariable logistic regression analysis was conducted to assess differential reporting across background characteristics.

Results

Among women who were ever sterilized, 78% reported currently using any contraceptive method(s), and 77% reported sterilization as the current method. Women in the lowest household wealth quintile or in general caste were less likely to report sterilization as a current method. Time since sterilization was not associated with correct reporting of sterilization.

Conclusion

This study demonstrates, in a population with high sterilization, that sterilization as a current contraceptive method would be substantially underestimated using conventional survey questions. It highlights the importance of context-specific questionnaire adaptation to measure and monitor contraceptive use and provides implications in measuring current use of contraception in populations with high rates of sterilization.

Implications

The paper examined reporting of sterilization as a current method among sterilized women. Only 77% of sterilized women reported sterilization as a current contraceptive method. In a population with high sterilization, inclusion of a probe question in surveys is recommended to understand reporting quality and accurately measure contraceptive prevalence rates.

Estimating infertility prevalence in low-to-middle-income countries: an application of a current duration approach to Demographic and Health Survey data

STUDY QUESTION

Can infertility prevalence be estimated using a current duration (CD) approach when applied to nationally representative Demographic and Health Survey (DHS) data collected routinely in low- or middle-income countries?

SUMMARY ANSWER

Our analysis suggests that a CD approach applied to DHS data from Nigeria provides infertility prevalence estimates comparable to other smaller studies in the same region.

WHAT IS KNOWN ALREADY

Despite associations with serious negative health, social and economic outcomes, infertility in developing countries is a marginalized issue in sexual and reproductive health. Obtaining reliable, nationally representative prevalence estimates is critical to address the issue, but methodological and resource challenges have impeded this goal.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study was based on standard information available in the DHS core questionnaire and data sets, which are collected routinely among participating low-to-middle-income countries. Our research question was examined among women participating in the 2013 Nigeria DHS (n = 38 948). Among women eligible for the study, 98% were interviewed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We applied a CD approach (i.e. current length of time-at-risk of pregnancy) to estimate time-to-pregnancy (TTP) and 12-month infertility prevalence among women ‘at risk’ of pregnancy at the time of interview (n = 7063). Women who were 18–44 years old, married or cohabitating, sexually active within the past 4 weeks and not currently using contraception (and had not been sterilized) were included in the analysis. Estimates were based on parametric survival methods using bootstrap methods (500 bootstrap replicates) to obtain 95% CIs.

MAIN RESULTS AND THE ROLE OF CHANCE

The estimated median TTP among couples at risk of pregnancy was 5.1 months (95% CI: 4.2–6.3). The estimated percentage of infertile couples was 31.1% (95% CI: 27.9–34.7%)—consistent with other smaller studies from Nigeria. Primary infertility (17.4%, 95% CI: 12.9–23.8%) was substantially lower than secondary infertility (34.1%, 95% CI: 30.3–39.3%) in this population. Overall estimates for TTP >24 or >36 months dropped to 17.7% (95% CI: 15.7–20%) and 11.5% (95% CI: 10.2–13%), respectively. Subgroup analyses showed that estimates varied by age, coital frequency and fertility intentions, while being in a polygynous relationship showed minimal impact.

LIMITATIONS, REASONS FOR CAUTION

The CD approach may be limited by assumptions on when exposure to risk of pregnancy began and methodologic assumptions required for estimation, which may be less accurate for particular subgroups or populations. Unrecognized pregnancies may have also biased our findings; however, we attempted to address this in our exclusion criteria. Limiting to married/cohabiting couples may have excluded women who are no longer in a relationship after being blamed for infertility. Although probably rare in this setting, we lack information on couples undergoing infertility treatment. Like other TTP measurement approaches, pregnancies resulting from contraceptive failure are not included, which may bias estimates.

WIDER IMPLICATIONS OF THE FINDINGS

Nationally representative estimates of TTP and infertility based on a clinical definition of 12 months have been limited within developing countries. This approach represents a pragmatic advance in our ability to measure and monitor infertility in the developing world, with potentially far-reaching implications for policies and programs intended to address reproductive health.

STUDY FUNDING/COMPETING INTERESTS

There are no competing interests and no financial support was provided for this study. Financial support for Open Access publication was provided by the World Health Organization.

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.

A practical alternative to calculating unmet need for family planning

The standard approach for measuring unmet need for family planning calculates actual, physiological unmet need and is useful for tracking changes at the population level. We propose to supplement it with an alternate approach that relies on individual perceptions and can improve program design and implementation. The proposed approach categorizes individuals by their perceived need for family planning: real met need (current users of a modern method), perceived met need (current users of a traditional method), real no need, perceived no need (those with a physiological need for family planning who perceive no need), and perceived unmet need (those who realize they have a need but do not use a method). We tested this approach using data from Mali (n=425) and Benin (n=1080). We found that traditional method use was significantly higher in Benin than in Mali, resulting in different perceptions of unmet need in the two countries. In Mali, perceived unmet need was much higher. In Benin, perceived unmet need was low because women believed (incorrectly) that they were protected from pregnancy. Perceived no need - women who believed that they could not become pregnant despite the fact that they were fecund and sexually active - was quite high in both countries. We posit that interventions that address perceptions of unmet need, in addition to physiological risk of pregnancy, will more likely be effective in changing behavior. The suggested approach for calculating unmet need supplements the standard calculations and is helpful for designing programs to better address women's and men's individual needs in diverse contexts.

Design and methodology of a mixed methods follow-up study to the 2014 Ghana Demographic and Health Survey

BACKGROUND

The intended meaning behind responses to standard questions posed in large-scale health surveys are not always well understood. Systematic follow-up studies, particularly those which pose a few repeated questions followed by open-ended discussions, are well positioned to gauge stability and consistency of data and to shed light on the intended meaning behind survey responses. Such follow-up studies require extensive coordination and face challenges in protecting respondent confidentiality during the process of recontacting and reinterviewing participants.

OBJECTIVES

We describe practical field strategies for undertaking a mixed methods follow-up study during a large-scale health survey.

METHODS

The study was designed as a mixed methods follow-up study embedded within the 2014 Ghana Demographic and Health Survey (GDHS). The study was implemented in 13 clusters. Android tablets were used to import reference data from the parent survey and to administer the questionnaire, which asked a mixture of closed- and open-ended questions on reproductive intentions, decision-making, and family planning.

RESULTS

Despite a number of obstacles related to recontacting respondents and concern about respondent fatigue, over 92 percent of the selected sub-sample were successfully recontacted and reinterviewed; all consented to audio recording. A confidential linkage between GDHS data, follow-up tablet data, and audio transcripts was successfully created for the purpose of analysis.

CONCLUSIONS

We summarize the challenges in follow-up study design, including ethical considerations, sample size, auditing, filtering, successful use of tablets, and share lessons learned for future such follow-up surveys.

Personalised estimation of a woman's most fertile days

OBJECTIVES

We propose a new, personalised approach of estimating a woman's most fertile days that only requires recording the first day of menses and can use a smartphone to convey this information to the user so that she can plan or prevent pregnancy.

METHODS

We performed a retrospective analysis of two cohort studies (a North Carolina-based study and the Early Pregnancy Study [EPS]) and a prospective multicentre trial (World Health Organization [WHO] study). The North Carolina study consisted of 68 sexually active women with either an intrauterine device or tubal ligation. The EPS comprised 221 women who planned to become pregnant and had no known fertility problems. The WHO study consisted of 706 women from five geographically and culturally diverse settings. Bayesian statistical methods were used to design our proposed method, Dynamic Optimal Timing (DOT). Simulation studies were used to estimate the cumulative pregnancy risk.

RESULTS

For the proposed method, simulation analyses indicated a 4.4% cumulative probability of pregnancy over 13 cycles with correct use. After a calibration window, this method flagged between 11 and 13 days when unprotected intercourse should be avoided per cycle. Eligible women should have cycle lengths between 20 and 40 days with a variability range less than or equal to 9 days.

CONCLUSIONS

DOT can easily be implemented by computer or smartphone applications, allowing for women to make more informed decisions about their fertility. This approach is already incorporated into a patent-pending system and is available for free download on iPhones and Androids.

Fertility Limitation and Child Schooling in Ouagadougou: Selective Fertility or Resource Dilution?

Using original data collected in Ouagadougou, Burkina Faso, this study investigates evidence for the competing theories that fertility reductions increase children's education through either the quantity-quality tradeoff (intentionally choosing smaller families to make greater investments in education and other indicators of child quality) or resource dilution (having more children reduces resources available per child, regardless of intentionality of family size). The results provide evidence for both hypotheses: children having four or fewer siblings were significantly more likely to be enrolled in school if their mothers had intentionally stopped childbearing relative to those whose mothers wanted more children but whose childbearing was limited by subfecundity. The difference between intentional and unintentional family limitation was not significant for parities greater than five. In addition, the relationship between number of siblings and their schooling is negative, regardless of the intentionality of family-size limitation, but the strength of this negative relationship is approximately twice as high among children whose mothers intentionally limited fertility (reflecting both selection and dilution effects) than among children whose mothers were subfecund (reflecting the pure dilution effect).

Unmet need for contraception: issues and challenges

Unmet need for contraception has been a central indicator for monitoring the progress of family planning programs for 25 years. The purpose of this article is to provide a broad context for the more focused contributions that follow in this special issue. The validity and measurement of the concept of unmet need are discussed. We then present regional trends among married women since 1970. Major reductions in unmet need have been achieved, with the clear exception of sub-Saharan Africa. Less success can be claimed in addressing the needs of sexually active unmarried women, who contribute nearly 20 percent to overall unmet need in developing countries. Prominent reasons for unmet need in settings where contraceptive uptake is low include social resistance and insufficient information concerning methods. As contraceptive use increases, the importance of these reasons wanes, but concerns regarding side effects and health impact remain a barrier, and discontinued users now constitute a large proportion of those with unmet need. Drawing on these reasons, we outline measures to further reduce unmet need.