Couples' unmet need for family planning in three West African countries

Reassessing the level and implications of male involvement in family planning in Indonesia

BACKGROUND

Although there is global recognition of the importance of involving men in family planning and reproductive health matters, this issue has received insufficient attention in many countries. The present study sought to characterize married Indonesian males as to their level of involvement in family planning, identify the correlates thereof and assess the implications of male involvement for unmet need for family planning.

METHODS

A mixed methods research design was used. The main source of quantitative data was 2017 Indonesian Demographic Health Survey (IDHS) data from 8,380 married couples. The underlying "dimensions" of male involvement were identified via factor analysis. The correlates of male involvement were assessed via comparisons across the four dimensions of male involvement identified in the factor analysis. Outcomes were assessed by comparing women's and couple's unmet need for family planning for the four underlying dimensions of male involvement. Qualitative data were collected via focus group discussions with four groups of key informants.

RESULTS

Indonesian male involvement as family planning clients remains limited, with only 8% of men using a contraceptive method at the time of the 2017 IDHS. However, factor analyses revealed three other independent "dimensions" of male involvement, two of which (along with male contraceptive use) were associated with significantly lower odds of female unmet need for family planning. Male involvement as clients and passive male approval of family planning, which in Indonesia empowers females take action to avoid unwanted pregnancies, were associated with 23% and 35% reductions in female unmet need, respectively. The analyses suggest that age, education, geographic residence, knowledge of contraceptive methods, and media exposure distinguish men with higher levels of involvement. Socially mandated gender roles concerning family planning and perceived limited programmatic attention to males highlight the quantitative findings.

CONCLUSIONS

Indonesian males are involved in family planning in several ways, although women continue to bear most of the responsibility for realizing couple reproductive aspirations. Gender transformative programming that addresses broader gender issues and targets priority sub-groups of men as well as health service providers, community and religious leaders would seem to be the way forward.

Unwanted Family Planning: Prevalence Estimates for 56 Countries

While there is a large literature on the prevalence of unmet need for family planning, there is no matching quantitative evidence on the prevalence of unwanted family planning; all contraceptive use is assumed to represent a "met need." This lack of evidence raises concerns that some observed contraceptive use may be undesired and coercive. We provide estimates of unwanted family planning using Demographic and Health Survey data collected from 1,546,987 women in 56 low- and middle-income countries between 2011 and 2019. We estimate the prevalence of unwanted family planning, defined as the proportion of women who report wanting a child in the next nine months but who are using contraception. We find that 12.2 percent of women have an unmet need for family planning, while 2.1 percent have unwanted family planning, with estimated prevalence rates ranging from 0.4 percent in Gambia to 7.1 percent in Jordan. About half of unwanted family planning use can be attributed to condoms, withdrawal, and abstinence. Estimating the prevalence of unwanted family planning is difficult given current data collection efforts, which are not designed for this purpose. We recommend that future surveys probe the reasons for the use of family planning.

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.

Men, The Missing Link In Gender-equitable Family Planning: A Scoping Review

Background: Across societies, gender norms often allow men to hold key decision-making power within relationships, households and communities. This extends to almost all domains, consisting of family planning (FP) as well.  FP programs have largely engaged men as clients and rarely as equal partners or influencers although across lower- and middle-income countries (LMICs), and especially in South Asia, men hold key decision-making power on the domain of family planning. The objective of this article is to explore couple dynamics through the lens of spousal communication and decision-making and unpack male engagement and spousal dynamics in family planning. Methods: This review presents a synthesis of evidence from two peer-reviewed databases, PubMed and Jstor, and and insights from programmatic documents to shed light on gender equitable engagement of young married men in family planning. Inclusion and exclusion criteria for both these databases was set and search strategies were finalized. This was followed by title and abstract screening, data extraction, synthesis and analysis. Results: Study participants included unmarried men (16%, n=8), married men (19%, n=9), married women (19%, n=9), married couples (25%, n=12) or more than two respondent categories (21%, n=10). Almost three quarters (71%, n=34) of the studies selected had FP as the primary area of inquiry. Other prominent thematics on which the studies reported were around norms (n=9, 16%), couple dynamics and intimacy (n=12, 22%). Conclusions: The evidence presented provides sufficient impetus to expand on gender-equitable male engagement, viewing men as equal and supportive partners for informed, equitable and collaborative contraceptive uptake and FP choices by couples.

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

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

Factors associated with modern contraceptive demands satisfied among currently married/in-union women of reproductive age in Ethiopia: a multilevel analysis of the 2016 Demographic and Health Survey

OBJECTIVES

Regardless of the local and international initiatives, excluding exempting services, demand satisfied for contraceptives remains low in Ethiopia. This circumstance is supposed to be attributed to different level factors; however, most were not well addressed in the previous studies. Therefore, this study aimed at assessing the magnitude and individual, household and community-level factors associated with demand satisfied for modern contraceptive (DSFMC) methods among married/in-union women of reproductive age.

DESIGN

Cross-sectional study.

SETTING

A community-based study across the country.

PARTICIPANTS

Randomly selected 9126 married/in-union women had participated using a structured questionnaire.

OUTCOME

DSFMC methods among married/in-union women of reproductive age.

RESULTS

DSFMC methods in Ethiopia was 39.5% (95% CI 38.5% to 40.5%). Women aged 35-49 years (adjusted OR (AOR): 0.43, 95% CI 0.32 to 0.58), Muslim religion (AOR: 0.58, 95% CI0.43 to 0.78), husband lived elsewhere (AOR: 0.42, 95% CI 0.29 to 0.60), joint decision making to use (AOR: 1.30, 95% CI 1.04 to 1.62), good knowledge (AOR: 1.57, 95% CI 1.32 to 1.86) and wealth status of poorer (AOR: 1.56, 95% CI 1.17 to 2.06), middle (AOR: 1.77, 95% CI 1.33 to 2.35), richer (AOR: 1.96, 95% CI 1.49 to 2.59), and richest (AOR: 1.49, 95% CI 1.05 to 2.08), pastoralist regions (AOR: 0.28, 95% CI 0.18 to 0.42), and agrarian regions (AOR: 1.72, 95% CI 1.21 to 2.44) and rural residency (AOR: 0.56, 95% CI 0.37 to 0.82) were factors significantly associated.

CONCLUSIONS

Women's age, religion, the current living place of husbands and women's knowledge were individual-level factors. Household wealth status and mutual decision making to use were household-level factors. Region and residency were households and community-level factors associated with DSFMCs. Increasing the accessibility of modern contraceptive methods to women in rural areas and pastoralist regions, those living separately, engaging religious leaders and men in the programme, would increase their satisfying demand.

The role of partner influence in contraceptive adoption, discontinuation, and switching in a nationally representative cohort of Ugandan women

BACKGROUND

Understanding contraceptive use dynamics is critical to addressing unmet need for contraception. Despite evidence that male partners may influence contraceptive decision-making, few studies have prospectively examined the supportive ways that men influence women's contraceptive use and continuation.

OBJECTIVE

This study sought to understand the predictive effect of partner influence, defined as partner's fertility intentions and support for contraception, and discussions about avoiding pregnancy prior to contraceptive use, on contraceptive use dynamics (continuation, discontinuation, switching, adoption) over a one-year period.

METHODS

This study uses nationally representative longitudinal data of Ugandan women aged 15-49 collected in 2018-2019 (n = 4,288 women baseline; n = 2,755 women one-year follow-up). Two analytic sub-samples of women in union and in need of contraception at baseline were used (n = 618 contraceptive users at baseline for discontinuation/switching analysis; n = 687 contraceptive non-users at baseline for adoption analysis). Primary dependent variables encompassed contraceptive use dynamics (continuation, discontinuation, switching, and adoption); three independent variables assessed partner influence. For each sub-sample, bivariate associations explored differences in sociodemographic and partner influences by contraceptive dynamics. Multinomial regression models were used to examine discontinuation and switching for contraceptive users at baseline; logistic regression identified predictors of contraceptive adoption among non-users at baseline.

RESULTS

Among users at baseline, 26.3% of women switched methods and 31.5% discontinued contraceptive use by follow-up. Multinomial logistic regression, adjusting for women's characteristics, indicated the relative risk of contraceptive discontinuation doubled when women did not discuss pregnancy avoidance with their partner prior to contraceptive use. Partner influence was not related to method switching. Among non-users at baseline, partner support for future contraceptive use was associated with nearly three-fold increased odds of contraceptive adoption.

SIGNIFICANCE

These results highlight the potentially supportive role of male partners in contraceptive adoption. Future research is encouraged to elucidate the complex pathways between couple-based decision-making and contraceptive dynamics through further prospective studies.

Knowledge, attitudes, and practices related to family planning and gender equity among husbands of adolescent girls in Niger

Despite having the highest fertility rate in the world, research on Niger men and family planning (FP) is limited. We collected survey data collected in the Dosso region of Niger in 2016 from 1136 men who are the husbands of adolescent girls. We report descriptive statistics, bivariate and multivariable logistic regression on three dichotomous outcomes: (a) knowledge of modern contraceptives, (b) beliefs that only husbands should make FP decisions, and (c) current FP use. About 56% had ever heard of the pill, 6% had ever heard of an intrauterine device, and 45% had ever heard of an injectable. In our multivariable analyses, we found: a man knowing at least one modern method was significantly associated with his age, wife’s education level, gender ideology, and wife’s say in healthcare decisions; men’s belief that men alone should make FP decisions was associated with husband’s Quranic education, gender ideology, and attitudes towards violence against women; men’s reports of adolescent wives’ current family planning use was associated with men’s Quranic education, women’s involvement in her own healthcare decisions, and belief that men alone should decide about family planning. Finding suggests that interventions should target aim to reduce gender inequities to increase family planning utilisation.

Impact of internal female migration on unmet need for modern contraception in Zambia

Background

Unmet need for contraception, the proportion of women who want to limit or delay childbirth but use no form of contraception, is the core indicator to evaluate the effectiveness of family planning programs. Understanding how migration influences unmet need is important to identify to whom and how to target sexual and reproductive health programs. We assessed how migration status in rural and urban settings is associated with having an unmet need for family planning.

Methods

Data on sexually active, fecund, reproductive-aged (15–49 years) women from the 2013–14 Zambia Demographic and Health Survey were analysed through univariate and multivariate logistic regression models.

Results

Unmet need for modern contraceptive methods was significantly higher among rural to rural migrant women (OR 1.30, 95%CI 1.00–1.70 p < 0.05) and rural non-migrant women (OR 1.41, 95%CI 1.06–1.85 p < 0.01) compared to urban non-migrant women after controlling for age, marital status, parity, religion, education and wealth.

Conclusion

Women residing in, and migrating between, rural areas were significantly more likely to have an unmet need for contraception. Our findings highlight the importance of understanding migration and migrant streams to strengthen family planning programs. In Zambia, a focus on rural-rural migrants, rural non-migrants and the poorest could improve the health of the entire population.

Family Planning Adoption and Unmet Needs: Spousal Agreement in Rural Varanasi

Background

There have been very few studies in India where both partners' involvement in family planning is seen. The present study was undertaken to assess the spousal agreement level regarding family planning adoption and unmet needs.

Materials and Methods

Married couples where wife was in reproductive age group (15-44 years) were included. A pretested, semi-structured interview schedule was used for the study. Sterilized couples were excluded. Interview of both husband and wife was done on the same day but in isolation.

Results

There was excellent to poor agreement was reported among husbands and wives in fertility desire (κ = 0.769), current use of contraception (κ = 0.581), unmet need for family planning (κ = 0.416), ideal family size (Spearman correlation = 0.329), and approval for the use of contraception (κ = 0.300). In 6.1% of cases, husband-only unmet need was reported.

Conclusion

There is need to encourage spousal communication so that they can make informed decisions on contraceptive choice. Husband-only unmet need for family planning was found, so man may be a potential entry point of national demographic health surveys to improve the contraceptive usage among couples and reduce the unmet need of them.

Socio-Cultural Challenges of Family Planning Initiatives for Displaced Populations in Conflict Situations and Humanitarian Settings

Provision of family planning services for refugee populations in conflict and humanitarian settings has been improving. Availability of services, however, does not translate into acceptability and uptake; understanding socio-cultural settings and barriers is critical to ensure utilization of services. Misconceptions and apprehensions surrounding family planning services are common. Populations may see limiting pregnancies as counterproductive in light of high child mortality or suspicious in the context of ethnic violence; larger family size has the perceived advantage of additional security for the community or ethnic group, assistance with family duties in a subsistence structure, and a social service investment for parents as they age; and there may be religious and moral objections to contraception. Any service planning and implementation must take into account community perceptions and address socio-cultural contextual subtleties. Ongoing community education via local initiatives from within the refugee community, region-wide structural strategies for service implementation and sustainability, and efforts to reconcile reproductive rights and family planning services within the religious and social context are crucial. (Disaster Med Public Health Preparedness. 2018;12:670-674).

Modeling the impact of novel male contraceptive methods on reductions in unintended pregnancies in Nigeria, South Africa, and the United States

OBJECTIVE

We modeled the potential impact of novel male contraceptive methods on averting unintended pregnancies in the United States, South Africa, and Nigeria.

STUDY DESIGN

We used an established methodology for calculating the number of couple-years of protection provided by a given contraceptive method mix. We compared a "current scenario" (reflecting current use of existing methods in each country) against "future scenarios," (reflecting whether a male oral pill or a reversible vas occlusion was introduced) in order to estimate the impact on unintended pregnancies averted. Where possible, we based our assumptions on acceptability data from studies on uptake of novel male contraceptive methods.

RESULTS

Assuming that only 10% of interested men would take up a novel male method and that users would comprise both switchers (from existing methods) and brand-new users of contraception, the model estimated that introducing the male pill or reversible vas occlusion would decrease unintended pregnancies by 3.5% to 5.2% in the United States, by 3.2% to 5% in South Africa, and by 30.4% to 38% in Nigeria. Alternative model scenarios are presented assuming uptake as high as 15% and as low as 5% in each location. Model results were sensitive to assumptions regarding novel method uptake and proportion of switchers vs. new users.

CONCLUSION

Even under conservative assumptions, the introduction of a male pill or temporary vas occlusion could meaningfully contribute to averting unintended pregnancies in a variety of contexts, especially in settings where current use of contraception is low.

IMPLICATIONS

Novel male contraceptives could play a meaningful role in averting unintended pregnancies in a variety of contexts. The potential impact is especially great in settings where current use of contraception is low and if novel methods can attract new contraceptive users.

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.