How the Community Shapes Unmet Need for Modern Contraception: An Analysis of 44 Demographic and Health Surveys

Assessing the effect of concerns about contraceptive-induced fertility impairment on hormonal contraceptive use by parity and residence: evidence from PMA Ethiopia 2020 cross-sectional survey

OBJECTIVES

This study aims to describe patterns of beliefs about contraceptive-induced infertility and assess their relationship with current contraceptive use, including whether these relationships vary by parity and residence.

DESIGN

We use data from Performance Monitoring for Action Ethiopia, a nationally representative, cross-sectional survey of 7491 women, aged 15-49, to assess agreement with the statement 'If I use family planning, I may have trouble getting pregnant next time I want to.' We used multilevel hierarchical models to identify the association between agreement and use of a hormonal method of contraception among 3882 sexually active, fecund women who wish to prevent pregnancy. We include interaction terms for parity and residence.

RESULTS

4 in 10 women disagreed (42.3%) and 2 in 10 strongly disagreed (20.7%) with the statement. Relative to women who strongly disagreed, women who disagreed and women who agreed had significantly lower odds of using a hormonal method of contraception (adjusted OR (aOR) 0.65, 95% CI 0.44 to 0.97 and 0.46, 95% CI 0.46, 95% CI 0.30 to 0.70). The effect of agreeing with the statement was strongest among high parity women (aOR 0.54, 95% CI 0.30 to 0.95). Greater agreement with the statement at the community-level use was associated with a reduction in the odds of using hormonal contraception but only among rural women.

CONCLUSIONS

Efforts to address concerns around contraceptive-induced fertility impairment through the provision of comprehensive counselling and through community education or mass media campaigns are necessary, particularly among high-parity women and in rural communities. Interventions should acknowledge the possibility of delayed return to fertility for specific methods and attempt to address the root causes of concerns.

Determinants of unmet need for family planning: Evidence from the 2018 Turkey Demographic and Health Survey

Unmet need for family planning is a valuable concept to indicate the discrepancy between women's fertility preferences and contraceptive use. Unmet need may lead to unintended pregnancies and unsafe abortions. These may result in health deterioration and reduced employment opportunities for women. The 2018 Turkey Demographic and Health Survey report indicated that the estimated unmet need for family planning doubled from 2013 to 2018, returning to the high levels of the late 1990s. Considering this unfavourable change, this study aims to investigate the determinants of unmet need for family planning among married women of reproductive age in Turkey by using the 2018 Turkey Demographic and Health Survey data. Logit model estimations revealed that women who were at older ages, more educated, wealthier, and had more than one child were less likely to have unmet need for family planning. Employment statuses of women and their spouses and place of residence were significantly associated with unmet need. Results emphasised that training and counselling to enhance the use of family planning methods should effectively target young, less educated, and poor women.

The impact of local supply of popular contraceptives on women's use of family planning: findings from performance-monitoring-for-action in seven sub-Saharan African countries

Contraceptive use has substantial implications for women's reproductive health, motivating research on the most effective approaches to minimize inequalities in access. When women prefer to limit or delay fertility but are not using contraception, this potentially reflects demand for contraception that is not being satisfied. Current literature emphasizes a nuanced integration of supply and demand factors to better understand this gap. In this research, we examine the interconnectedness of supply and demand factors both conceptually and methodologically by augmenting existing measures of local supply with a demand-side factor-community-level preferences for contraceptive methods. Using novel data from Performance Monitoring for Action (PMA) in seven sub-Saharan African countries, we test whether the available supply of locally preferred methods at nearby service delivery points (SDP) explains variation in women's uptake of contraception beyond the more typical measure of contraceptive stockouts. Findings from logistic regression analyses (N = 32,282) suggest that demand and supply can be understood as tightly interconnected factors which are directly affected by local social preferences. The odds of women using modern contraception increase significantly when locally preferred methods are available, and this is true even after controlling for the availability of methods in general. The new measure tested in this research centers women and their specific desires in a manner consistent with the promotion of contraceptives as an important human right.

Is the Decision Not to Use Contraception an Indicator of Reproductive Agency?

Women's engagement in the decision to use contraception, an indicator captured in the Demographic and Health Surveys (DHS), is frequently used to assess women's reproductive agency. In 2014, DHS added a corollary question to the women's questionnaire on decision-making not to use contraception. Study authors hypothesize that women's engagement in decision-making not to use contraception is also indicative of reproductive agency. Analyzing DHS microdata from 30 countries collected between 2015 and 2020 (n = 292,141), this country-level study examines data quality in terms of missingness of data (t-tests), indicator utility in terms of response pattern variability (descriptive statistics), and construct validity in terms of associations between engagement in the decision not to use contraception and engagement in household decision-making (multivariable linear regression). Findings indicate the measure is of good quality, provides nuanced insight, and has construct validity. Importantly, the new measure deepens our understanding of women's reproductive agency.

Contraceptive use among female head porters: implications for health policy and programming in Ghana

Objective

Despite the growing literature on the barriers to contraceptives use among women, the perspective of female head porters has not been exhaustively researched. Using Bronfenbrenner's socio-ecological theory, we explore the factors that influence the contraceptive decision-making of migrant female head porters in the Kumasi Metropolis and the implications for health policy and planning.

Methodology

A case study of female head porters in the Kumasi Metropolis was conducted. We employed a qualitative approach in the collection and analysis of the data. A combination of cluster, purposive, and convenience sampling procedures was used to select 48 migrant female head porters to participate in semi-structured in-depth interviews. The data collected were analyzed using the thematic analytical framework.

Results

We found the main barriers to the uptake of contraception among the head porters to include high cost of contraceptives, perceived side effects associated with contraceptive use, and the disapproval of a male sexual partners.

Conclusion

The findings indicate that head porters' contraceptive decision-making is largely influenced by their social and economic circumstances. To address these, we recommend a carefully tailored approach, starting with a free National Health Insurance Scheme (NHIS) enrollment policy for all head porters in the country. There is also the need for the Ghana Health Service, and NGOs in health to work together to create effective awareness among female head porters on the benefits and misconceptions of contraception by incorporating culturally appropriate education that would facilitate the adoption of positive attitudes towards contraception. Additionally, NGOs in health in collaboration with the health facilities should initiate a process that encourages joint reproductive health decision-making among partners which recognises the added value of men's participation. We argue that men's active participation in contraception decision-making could potentially address their scepticism towards uptake.

Prevalence and determinants of unmet need for contraception among women in low and high-priority segments for family planning demand generation in Nigeria

BACKGROUND

Studies have identified various determinants of unmet need for contraception. These determinants cut across individual, household, community, and health facility levels. Despite this evidence, there remains a lack of information regarding differentials in the prevalence and determinants of unmet need for contraception among women in the low-priority segments (such as women of advanced reproductive age and women living with disabilities) and high-priority segments (such as adolescents, young adults, and unmarried women) for family planning demand generation, hence this study.

METHODS

The study design is cross-sectional. The study analyzed merged data from the individual, and persons recode of the 2018 Nigeria Demographic and Health Survey (NDHS). The samples analyzed are 5,147 women in the high-priority segment and 7,536 women in the low-priority segment. The outcome variable in the study was unmet need for contraception. The explanatory variables were selected at the individual, household, community, and facility levels. Statistical analyzes were performed using Stata 14. Three multilevel mixed-effects regression models were fitted. Model 1 was the empty model, while Model 2 included the sets of individual, household, and community variables. Model 3 controlled for the facility-level variables.

RESULTS

Findings show a higher prevalence of unmet need for contraception among women in the family planning low-priority segment compared to women in the family planning high-priority segment. Religion and desired family size were the two individual characteristics that significantly predicted the unmet need for contraception among women in the two segments. Sexual autonomy was the only household characteristic that predicted unmet need for contraception in both segments. There were differences in the community characteristics that predicted unmet need for contraception among women in the two segments.

CONCLUSION

The prevalence of unmet need for contraception is not the same among women in low and high family planning priority segments. The determinants also differ among women in the two segments. Though, women in different family planning segments have the same contraceptive needs of avoiding pregnancy when not needed, however, getting the needs satisfied requires that existing programs be further examined to develop initiatives that will resonate with each segment of reproductive-age women.

Structural Context and the Role of Positive Deviance From Community Norms in Shaping Risk for Sexual Intimate Partner Violence in 32 Low- and Middle-Income Countries

Community norms provide social scripts and pathways to accruing social capital that can alter a woman's risk of experiencing sexual intimate partner violence (IPV). These norms are in turn influenced by the structural environment in which they exist. Missing from the literature is an understanding of how an individual's departure from community norms-positive deviance-influences the risk of sexual IPV and how this effect may vary across structural environments. Demographic and Health Survey data from 32 low- and middle-income countries (LMIC) were stratified into six structural environments by two fundamental structural factors: level of gender inequality and prevalence of sexual IPV. To examine how transcending community norms shape the odds of reporting sexual IPV across environments, six identical multilevel models were fit including statistical deviation from 13 community norms as key covariates. Positive deviance from community norms is associated with both increased and decreased odds of reporting sexual IPV and the nature of these relationships vary by structural environment. Positive deviance had a greater effect on reporting sexual IPV in highly unequal societies. Positive deviance from fertility preferences and controlling behavior was associated with increased odds of sexual IPV across contexts. The accrual of social capital and differences in female autonomy across environments may be two ways positive deviance alters sexual IPV risk. A better understanding of how the salience of community norms varies by structural environment and how transcending these norms shapes the risk for sexual violence may help highlight pathways for interventions to change restrictive social norms and increase female empowerment without increasing the risk of sexual IPV.

Empowerment and use of modern contraceptive methods among married women in Burkina Faso: a multilevel analysis

BACKGROUND

In Burkina Faso, gender inequality prevents women from meeting their reproductive needs, leading to high rates of unintended pregnancies, abortions and deaths. Evidence shows that empowering women may increase the proportion of demand for family planning satisfied using modern methods (mDFPS), but few studies have measured this process in multiple spheres of life. We investigated how empowerment influences the mDFPS among married women of reproductive age (MWRA) in Burkina Faso.

METHODS

We analyzed data from the 2010 Burkina Faso Demographic and Health Survey (DHS) on 4714 MWRA with reproductive needs living in 573 communities. We used principal component analysis (PCA) and Cronbach's alpha test to explore and assess specific and consistently relevant components of women's agency in marital relationships. Aggregated measures at the cluster level were used to assess gender norms and relationships in communities. Descriptive statistics were performed and multilevel logistic regression models were carried out to concurrently gauge the effects of women's agency and community-level of gender equality on mDFPS, controlling for socioeconomic factors.

RESULTS

Overall, less than one-third (30.8%) of the demand for family planning among MWRA were satisfied with modern methods. Participation in household decision-making, freedom in accessing healthcare, and opposition to domestic violence were underlying components of women's agency in marital relationships. In the full model adjusted for socioeconomic status, freedom in accessing healthcare was significantly (aOR 1.27, CI 1.06-1.51) associated with mDFPS. For community-level variables, women's greater access to assets (aOR 1.72, 95% CI 1.13-2.61) and family planning messages (aOR 2.68, 95% CI 1.64-4.36) increased mDFPS, while higher fertility expectations (aOR 0.75, 95% CI 0.64-0.87) reduced it. Unexpectedly, women in communities with higher rates of female genital mutilation were more likely (aOR 2.46, 95% CI 1.52-3.99) to have mDFPS.

CONCLUSIONS

Empowering women has the potential to reduce gender inequality, raise women's agency and increase mDFPS. This influence may occur through both balanced marital relationships and fair community gender norms and relationships. Progress toward universal access to reproductive services should integrate the promotion of women's rights.

TRIAL REGISTRATION

No clinical trial has been performed in this study.

Age disparities in unmet need for contraception among all sexually active women in Colombia: Demographic Health Survey 2015

The Unmet need for contraception increases unintended pregnancies and jeopardizes women's health and reproductive rights. Social determinants are associated with an unmet need for contraception. Still, it is unclear if age is a social determinant of disparities in reproductive health-related outcomes in all Colombian women regardless of marital status. This study used the 2015 Colombian Demographic and Health Survey to determine the unmet need for contraception among 24,245 sexually active women aged 13-49. Age was associated with the unmet need for contraception using a multivariate analysis. Absolute and relative inequalities were estimated using differences in prevalence and odds ratios, respectively. The prevalence of unmet need for contraception was significantly higher in married women aged 13-19 years old (19.8%) than their unmarried counterparts (16.8%), and all older age groups either married or unmarried. Women 13-19 years old [OR = 2.98 (2.49-3.57)] and 20-29 years old [OR = 1.71(1.48-1.97)] are more likely to have an unmet need for contraception than those 40-49 years old. Age disparities are barriers to attaining the Sustainable Development Goals for sexual and reproductive health. Cultural, social, and access barriers demand societies to tailor health care services to meet younger women's needs to narrow the age gap.

Family Planning Beliefs and Their Association with Contraceptive Use Dynamics: Results from a Longitudinal Study in Uganda

Norms and beliefs toward contraception, both positive and negative, motivate contraceptive use; however, they have seldom been explored longitudinally in low‐ and middle‐income countries, limiting our understanding of their influence on contraceptive dynamics. We used PMA2020 Uganda national longitudinal data of reproductive aged women in 2018 (baseline) and 2019 (follow‐up) to explore discontinuation and switching among modern contraceptive users at baseline (n = 688) and contraceptive use at follow‐up among nonusers at baseline (n = 1,377). Multivariable simple and multinomial logistic regressions assessed the association of individual and community‐level contraceptive beliefs with contraceptive uptake, discontinuation and switching. One‐quarter of nonusers at baseline were using contraception at follow‐up, while 37 percent of users at baseline had discontinued and 28 percent had switched methods at follow‐up. The odds of contraceptive uptake were lower among women who strongly agreed that contraception impacted future fertility or caused conflict within a couple, relative to those who strongly disagreed (adjusted odds ratio (aOR): 0.7 and aOR: 0.6, respectively), but higher among women who strongly agreed that contraception preserved beauty (aOR: 1.6). Women who strongly agreed that it was acceptable to use contraception before having children were less likely to discontinue their method than those who strongly disagreed (adjusted relative risk ratio (aRRR): 0.5), though living in a community where more women agreed with this statement was associated with higher discontinuation (aRRR: 6.0). Family planning programs that promote positive beliefs toward family planning could improve contraceptive uptake and continuation. More research is needed to understand how contraceptive beliefs shape contraceptive decisions across the life course.

Misconceptions and Unmet Need for Modern Contraception among Cambodian Females: A Mix Methods Study

(1) Background: Women using unreliable traditional contraception need to be included in the proportion of women having an ‘unmet need for modern contraception’ instead of the current classification which presumes they have a ‘met need’. (2) Methods: Mix methods research design comprising initial quantitative analyses utilizing data from the nationally representative 2014 Cambodian Demographic and Health Survey (CDHS) for 4823 Cambodian, sexually active females aged 15–29 years. Then a qualitative phase explored knowledge about the menstrual cycle and misconceptions about modern contraception with 30 females aged 15–29 years in urban Cambodia using semi-structured interviews, transcribed verbatim with quality checks. Purposive and snowball sampling strategies were used until data saturation was reached. Inductive thematic data analysis was conducted; (3) Results: Unmet need for modern contraception increased to 25.4% when traditional contraception users were included. The qualitative themes show women have a lack of information about the menstrual cycle and misconceptions about modern contraception which contributed to increased use of traditional contraception; (4) Conclusion: Major drivers of increased unmet need for modern contraception include lack of literacy, misconceptions and low autonomy to choose modern contraception. Cambodia needs to endorse a policy shift to implement targeted, countrywide sexual and reproductive health literacy and family planning services.

Access to primary health care family planning services and contraceptive use in disadvantaged women: a qualitative study

OBJECTIVES

The study aimed to provide a deeper understanding of the gender-related determinants and organisational structure of primary health care that shape contraceptive use among disadvantaged women living in a developing Islamic country where family planning services are affected by health care reforms.

METHODS

A qualitative study was conducted in three disadvantaged neighbourhoods in the metropolitan district of Bornova, Izmir. A purposive sampling method with maximum diversity was used to obtain a study sample of 43 women. Data were collected through in-depth interviews and analysed using a coding paradigm of grounded theory.

RESULTS

Three themes emerged from the analysis, namely, factors affecting participants' number of children, experiences with using contraceptive methods, and use of family planning services at family health centres. Despite a desire to limit their number of children and a positive view of contraception, women in the study faced gender-related barriers to accessing family planning services. Their statements indicate significant deficiencies in terms of provision of contraception and family planning consultations at family health centres.

CONCLUSION

For disadvantaged women living in conservative areas, family planning is a fragile exercise. Gender-sensitive primary care services are essential to ensure access to everyone in the community.

Individual and community-level factors associated with unmet need for contraception among reproductive-age women in Ethiopia; a multi-level analysis of 2016 Ethiopia Demographic and Health Survey

BACKGROUND

There is limited evidence on the unmet need for contraceptives among married reproductive-age women especially in developing countries like Ethiopia. Thus, this study aimed to assess individual and community-level factors associated with unmet need for contraception among reproductive-age women in Ethiopia.

METHOD

A secondary analysis was done on the 2016 Ethiopian Demographic and Health Survey (EDHS) dataset which were collected cross-sectional. A total of 9056 women who were fecund, married and/or sexually active were included in the analysis. Multi-level mixed-effect logistic regression analysis was done by STATA version 14.0 to identify individual and community-level factors. Adjusted odds ratio with 95% confidence interval was used to show the strength and direction of the association and statistical significance was declared at P value less than 0.05.

RESULT

Factors significantly associated with unmet need were; ages of women between 45 and 49 years [AOR = 2.25, 95% CI: (1.34, 3.79)], greater than or equal to three living children [AOR = 1.87, 95% CI: (1.40, 2.49)], belong to richer household [AOR = 0.73, 95% CI: (0.54, 0.97)], Muslim followers [AOR = 1.37, 95% CI: (1.02, 1.83)], married more than once [AOR = 1.31, 95% CI: (1.06, 1.62)]. From community level variables: belong to the Somali region [AOR = 0.34, 95% CI: (0.19, 0.61)] were significantly associated with unmet need.

CONCLUSION

Both individual and community-level factors were significant determinants of unmet need. From individual-level factors: advanced ages of women, many total numbers of living children, live in the richer wealth quintile, being Muslim follower and married more than once and from community-level variables: belong to the Somali region were significantly associated with unmet need for contraception. The findings suggested that health care providers should mainly focus on women nearly on menopauses, who live in the poorest household and who had many numbers of living children and married more than once to decrease the unmet need for contraceptives.

Political Environment and Perceptions of Social Inclusion After Nationwide Marriage Equality Among Partnered Men Who Have Sex with Men in the USA

The aim of this paper is to examine how nationwide marriage equality and minority stressors are associated with perceptions of social inclusion using a national sample of partnered men who have sex with men (MSM)(n=498). A four-item scale measuring changes in perceived social inclusion due to the nationwide legalization of same-sex marriage was created. Respondents were categorized into four distinct political environments using results from the 2016 US Presidential election. Multilevel modeling was used to examine associations between political environment, minority stressors, and perceived social inclusion. Changes in perceived social inclusion due to marriage equality did not significantly differ between political environments. Higher levels of internalized, anticipated, and enacted stigma were all associated with fewer gains in perceived social inclusion. An interaction between political environment and external stigma was significant in the most politically conservative areas. The legalization of marriage equality has improved perceived social inclusion overall, but less so among men who experience more discrimination and live in conservative environments. Multilevel interventions to change social norms are needed to help decrease minority stressors and improve perceived social inclusion in politically conservative areas with elevated levels of discrimination.

Community influences on modern contraceptive use among young women in low and middle-income countries: a cross-sectional multi-country analysis

Background

Despite investment in family planning programs and education, unmet need for family planning remains high among young women (aged 15–24) in low and middle-income countries, increasing the risk for unwanted pregnancies and adverse social and reproductive health outcomes. There is a dearth of cross-national research that identifies the differential impact of community level factors among youth in low and middle-income countries (LMICs), which is imperative for the design of structural level interventions aimed at increasing family planning use.

Methods

Grounded in the socio-ecological framework, this paper utilizes Demographic and Health Survey (DHS) from 52 LMICs to examine the influence of community level reproductive, gender, fertility, literacy and economic indicators on modern contraceptive use among female youth. Analyses are conducted using multi-level logistic regressions with random community-level effects.

Results

Our findings highlight the positive influence of community level education attainment and negative influence of gender and fertility related norms on young women’s contraceptive use. Additionally, increased exposure to mass media did not positively influence young women’s uptake of modern contraceptive methods.

Conclusions

Taken together, findings indicate that young women’s contraceptive decision-making is greatly shaped by their social contexts. The commonalities and regional variations in community level influences provide support for both structural level interventions and tailored regional approaches to family planning interventions.