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Bullington BW, Sawadogo N, Tumlinson K, Langer A, Soura A, Zabre P, Sie A, Senderowicz L. Prevalence of non-preferred family planning methods among reproductive-aged women in Burkina Faso: results from a cross-sectional, population-based study. Sex Reprod Health Matters 2023; 31:2174244. [PMID: 37195714 PMCID: PMC10193871 DOI: 10.1080/26410397.2023.2174244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Family planning researchers have traditionally focused efforts on understanding contraceptive non-use and promoting contraceptive uptake. Recently, however, more scholars have been exploring method dissatisfaction, questioning the assumption that contraceptive users necessarily have their needs met. Here, we introduce the concept of "non-preferred method use", which we define as the use of one contraceptive method while having the desire to use a different method. Non-preferred method use reflects barriers to contraceptive autonomy and may contribute to method discontinuation. We use survey data collected from 2017 to 2018 to better understand non-preferred contraceptive method use among 1210 reproductive-aged family planning users in Burkina Faso. We operationalise non-preferred method use as both (1) use of a method that was not the user's original preference and (2) use of a method while reporting preference for another method. Using these two approaches, we describe the prevalence of non-preferred method use, reasons for using non-preferred methods, and patterns in non-preferred method use by current and preferred methods. We find that 7% of respondents reported using a method they did not desire at the time of adoption, 33% would use a different method if they could and 37% report at least one form of non-preferred method use. Many women cite facility-level barriers, such as providers refusing to give them their preferred method, as reasons for non-preferred method use. The high prevalence of non-preferred method use reflects the obstacles that women face when attempting to fulfil their contraceptive desires. Further research on reasons for use of non-preferred methods is necessary to promote contraceptive autonomy.
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Affiliation(s)
- Brooke W. Bullington
- PhD Student, Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, USA
- Predoctoral Trainee, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Nathalie Sawadogo
- Senior Lecturer, Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Ouagadougou, Burkina Faso
| | - Katherine Tumlinson
- Faculty Fellow, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Assistant Professor, Department of Maternal Child Health, University of North Carolina Gillings School of Global Public Health, Chapel Hill, USA
| | - Ana Langer
- Professor of the Practice of Public Health, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, BostonMA, USA
| | - Abdramane Soura
- Director, Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Ouagadougou, Burkina Faso
| | - Pascal Zabre
- Demographer, Head of HDSS, Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ali Sie
- Director, Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Leigh Senderowicz
- Alumna, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, BostonMA, USA
- Assistant Professor, Department of Gender and Women’s Studies, University of Wisconsin–Madison, MadisonWI, USA
- Assistant Professor, Department of Obstetrics and Gynecology, University of Wisconsin–Madison, MadisonWI, USA
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2
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Montt-Maray E, Adamjee L, Horanieh N, Witt A, González-Capella T, Zinke-Allmang A, Cislaghi B. Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review. Front Glob Womens Health 2023; 4:1149632. [PMID: 37674903 PMCID: PMC10478786 DOI: 10.3389/fgwh.2023.1149632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023] Open
Abstract
Background Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population. Methods We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review. Results Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services. Conclusion The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.
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Affiliation(s)
- Eloisa Montt-Maray
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lamiah Adamjee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Nour Horanieh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alice Witt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thaïs González-Capella
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anja Zinke-Allmang
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Beniamino Cislaghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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3
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Sarnak D, Anglewicz P, Ahmed S. Unmet need and intention to use as predictors of adoption of contraception in 10 Performance Monitoring for Action geographies. SSM Popul Health 2023; 22:101365. [PMID: 36909928 PMCID: PMC9996096 DOI: 10.1016/j.ssmph.2023.101365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 01/17/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
The determinants of fertility typically feature demand as the key motivation driver for contraceptive use. Yet relatively little is known about the extent to which demand for contraception predicts future contraceptive use, primarily due to the lack of longitudinal data that captures these measures at different time points. Two ways in which demand is often measured are unmet need and intention to use. Despite its intended use as a population measure, unmet need is commonly used in individual-level analyses and as a marker for individual-level demand for contraception. Few studies have assessed the extent to which unmet need predicts or reflects women's true latent demand as demonstrated by their future contraceptive use; the same is true for intention to use contraception in the future. We expand on previous research to assess whether and the degree to which unmet need and intention to use contraception predict adoption of contraception within a year, among nonusers in ten representative geographies using Performance Monitoring for Action (PMA) data. Findings show that in nine of ten sites, intention to use within a year was significantly associated with subsequent adoption, while in eight of ten sites, unmet need for spacing or limiting was not associated with adoption. Our results are important for programs as they try to identify true dynamic demand for contraception.
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Affiliation(s)
- Dana Sarnak
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Phil Anglewicz
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
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4
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Coulson J, Sharma V, Wen H. Understanding the global dynamics of continuing unmet need for family planning and unintended pregnancy. CHINA POPULATION AND DEVELOPMENT STUDIES 2023; 7:1-14. [PMID: 37193368 PMCID: PMC10075166 DOI: 10.1007/s42379-023-00130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/08/2023]
Affiliation(s)
- Justine Coulson
- United Nations Population Fund, China Office, Beijing, China
| | - Vinit Sharma
- United Nations Population Fund, Asia Pacific Regional Office, Bangkok, Thailand
| | - Hua Wen
- United Nations Population Fund, China Office, Beijing, China
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5
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Fabic MS, McDougal L, Raj A, Jadhav A. Is the Decision Not to Use Contraception an Indicator of Reproductive Agency? Stud Fam Plann 2023; 54:95-117. [PMID: 36790883 DOI: 10.1111/sifp.12235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
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.
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Affiliation(s)
- Madeleine Short Fabic
- Supervisory Public Health Advisor, United States Agency for International Development, Washington, DC, 20523, USA
| | - Lotus McDougal
- Assistant Professor, Center on Gender Equity and Health, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Anita Raj
- Professor, Director of the Center on Gender Equity and Health, University of California San Diego, San Diego, CA, USA
| | - Apoorva Jadhav
- Senior Technical Advisor for Demography and Health Policy, United States Agency for International Development, Washington, DC, 20523, USA
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6
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Senderowicz L, Bullington BW, Sawadogo N, Tumlinson K, Langer A, Soura A, Zabre P, Sie A. Assessing the Suitability of Unmet Need as a Proxy for Access to Contraception and Desire to Use It. Stud Fam Plann 2023; 54:231-250. [PMID: 36841972 PMCID: PMC10257191 DOI: 10.1111/sifp.12233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Unmet need for contraception is a widely used but frequently misunderstood indicator. Although calculated from measures of pregnancy intention and current contraceptive use, unmet need is commonly used as a proxy measure for (1) lack of access to contraception and (2) desire to use it. Using data from a survey in Burkina Faso, we examine the extent to which unmet need corresponds with and diverges from these two concepts, calculating sensitivity, specificity, and positive/negative predictive values. Among women assigned conventional unmet need, 67 percent report no desire to use contraception and 61 percent report access to a broad range of affordable contraceptives. Results show unmet need has low sensitivity and specificity in differentiating those who lack access and/or who desire to use a method from those who do not. These findings suggest that unmet need is of limited utility to inform family planning programs and may be leading stakeholders to overestimate the proportion of women in need of expanded family planning services. We conclude that more direct measures are feasible at the population level, rendering the proxy measure of unmet need unnecessary. Where access to and/or desire for contraception are the true outcomes of interest, more direct measures should be used.
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Affiliation(s)
- Leigh Senderowicz
- Department of Gender and Women’s Studies, University of Wisconsin-Madison, USA
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, USA
| | - Brooke W. Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, USA
| | - Nathalie Sawadogo
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Burkina Faso
| | - Katherine Tumlinson
- Carolina Population Center, University of North Carolina at Chapel Hill, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Ana Langer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, USA
| | - Abdramane Soura
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-ZERBO, Burkina Faso
| | - Pascal Zabre
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | - Ali Sie
- Centre de Recherche en Santé de Nouna, Burkina Faso
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7
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Bingenheimer JB, Hardee K, Hindin M, Jain A, Mumah J, Dam JV. Introduction to the Special Issue: Indicators in Sexual and Reproductive Health and Rights. Stud Fam Plann 2023; 54:9-16. [PMID: 36939037 DOI: 10.1111/sifp.12239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Affiliation(s)
| | | | | | - Aparna Jain
- Senior Director, Making Cents International & Chief of Party, CARE-GBV
| | - Joyce Mumah
- Technical Lead, Monitoring and Evaluation - WISH2ACTION, International Planned Parenthood Federation
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8
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Stevens R, Machiyama K, Mavodza CV, Doyle AM. Misconceptions, Misinformation, and Misperceptions: A Case for Removing the "Mis-" When Discussing Contraceptive Beliefs. Stud Fam Plann 2023; 54:309-321. [PMID: 36753058 DOI: 10.1111/sifp.12232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Beliefs about contraception are commonly conceptualized as playing an important role in contraceptive decision-making. Interventions designed to address beliefs typically include counseling to dispel any "myths" or "misconceptions." These interventions currently show little evidence for impact in reducing beliefs. This commentary delves into the problems associated with using implicitly negative terminology to refer to contraceptive beliefs, which come laden with assumptions as to their validity. By conceptualizing women as getting it wrong or their beliefs as invalid, it sets the scene for dubious treatment of women's concerns and hampers the design of fruitful interventions to address them. To replace the multitude of terms used, we suggest using "belief" going forward to maintain value-free curiosity and remove any implicit assumptions about the origin or validity of a belief. We provide recommendations for measuring beliefs to help researchers understand the drivers and impacts of the belief they are measuring. Finally, we discuss implications for intervention design once different types of belief are better understood. We argue that tailored interventions by belief type would help address the root causes of beliefs and better meet women's broader contraceptive needs, such as the need for contraceptive autonomy and satisfaction.
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Affiliation(s)
- Rose Stevens
- School of Anthropology and Museum Ethnography, University of Oxford, Oxford, UK
| | - Kazuyo Machiyama
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Constancia Vimbayi Mavodza
- Department of Public Health and Policy, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Aoife M Doyle
- Biomedical Research and Training Institute, Harare, Zimbabwe
- MRC International Statistics & Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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9
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Burke KL, Potter JE. Meeting Preferences for Specific Contraceptive Methods: An Overdue Indicator. Stud Fam Plann 2023; 54:281-300. [PMID: 36705876 DOI: 10.1111/sifp.12218] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.
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Affiliation(s)
- Kristen Lagasse Burke
- Population Research Center and Department of Sociology, University of Texas at Austin, Austin, TX, 78712, USA
| | - Joseph E Potter
- Population Research Center and Department of Sociology, University of Texas at Austin, Austin, TX, 78712, USA
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10
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Compton SD, Manu A, Maya E, Morhe ESK, Dalton VK. Give women what they want: contraceptive discontinuation and method preference in urban Ghana. Contracept Reprod Med 2023; 8:5. [PMID: 36642723 PMCID: PMC9841713 DOI: 10.1186/s40834-022-00200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/11/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Unmet need for contraception remains high in Ghana. Reducing the number of women who discontinue their contraceptive use is one way to decrease the number of women with an unmet need. In this study, we investigated factors associated with discontinuation among a cohort of Ghanaian women. METHODS Women who were beginning a new method of contraception at one of six urban clinics in Accra and Kumasi, Ghana were invited to participate in our study. Participants were interviewed before and after their counseling session, and at 3-, 6-, 9-, and 12-months post-enrollment to determine continuation. During follow-up, participants who were no longer using their method were asked why, if they were using any method of contraception, and if so, which method. Logistic regression analysis was performed to identify factors associated with discontinuation for reason other than pregnancy or desired pregnancy. RESULTS Of the 472 women who reported leaving their counseling session with a method, 440 (93.2%) had at least one follow-up contact. Of the 440 women, 110 (25%) discontinued their method at some point over the 12-month period, and 94 (85.5%) did so for reasons other than pregnancy or desired pregnancy. In the multivariate regression analysis, women who reported they were given their method of choice were 12.0% less likely to discontinue due to a non-pregnancy reason (p=0.005); those who used a long-acting reversible contraceptive (LARC) method were 11.1% less likely (p=.001); and those who reported they would choose to use that method again, one measure of satisfaction, were 23.4% less likely (p<.001). CONCLUSIONS To our knowledge, the current study is the first to explore method preference and its relation to continuation. Women in our study who reported they were given the contraceptive method of their choice were less likely to discontinue using that method for non-pregnancy-related reasons. Further, those who adopted a LARC method and those who reported they would make the same method choice again were less likely to discontinue. Women should be supported in selecting a contraceptive method of their choice. Providers should work with their clients to find a method which meets their preferences.
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Affiliation(s)
- Sarah D. Compton
- grid.214458.e0000000086837370University of Michigan Department of Obstetrics and Gynecology, 1500 E. Medical Center Dr, Ann Arbor, MI 48109 USA
| | - Adom Manu
- grid.8652.90000 0004 1937 1485Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, P. O. Box LG 13, Legon, Accra, Ghana
| | - Ernest Maya
- grid.8652.90000 0004 1937 1485Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, P. O. Box LG 13, Legon, Accra, Ghana
| | - Emmanuel S. K. Morhe
- grid.449729.50000 0004 7707 5975University of Health and Allied Sciences Department of Obstetrics and Gynaecology, PMB 31, Ho, Volta Region Ghana
| | - Vanessa K. Dalton
- grid.214458.e0000000086837370University of Michigan Department of Obstetrics and Gynecology, 1500 E. Medical Center Dr, Ann Arbor, MI 48109 USA
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11
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Rothschild CW, Richardson BA, Guthrie BL, Drake AL. Trajectories of method dissatisfaction among Kenyan women using modern, reversible contraception: A prospective cohort study. Contraception 2023; 117:22-24. [PMID: 36195189 DOI: 10.1016/j.contraception.2022.09.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Evidence on method dissatisfaction among current contraceptive users is sparse. Group-based trajectory modeling presents a novel approach to describing method dissatisfaction. STUDY DESIGN In a cohort of Kenyan women using modern contraception, we identified group-based trajectories of method dissatisfaction over 24 weeks since clinic visit. RESULTS Among 947 women, four trajectories were identified: consistent satisfaction (71%), increasing dissatisfaction (18%), decreasing dissatisfaction (8%), and consistent dissatisfaction (3%). DISCUSSION Method dissatisfaction was common in a cohort of Kenyan women. Group-based trajectory models describe distinct and changing experiences of contraceptive use. Deeper understanding of trajectories of contraceptive experience may be useful for advancing person-centered family planning care that addresses users' changing preferences and challenges.
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Affiliation(s)
- Claire W Rothschild
- Department of Epidemiology, University of Washington, Seattle, WA, United States.
| | - Barbra A Richardson
- Departments of Biostatistics and Global Health, University of Washington, Seattle, WA, United States; Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Brandon L Guthrie
- Department of Epidemiology, University of Washington, Seattle, WA, United States; Department of Global Health, University of Washington, Seattle, WA, United States
| | - Alison L Drake
- Department of Global Health, University of Washington, Seattle, WA, United States
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12
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Senderowicz L, Maloney N. Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs. POPULATION AND DEVELOPMENT REVIEW 2022; 48:689-722. [PMID: 36578790 PMCID: PMC9793870 DOI: 10.1111/padr.12478] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Leigh Senderowicz
- Leigh Senderowicz is Health Disparities Research Scholar, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, Wisconsin, USA and Postdoctoral Affiliate, Center for Demography and Ecology, University of Wisconsin-Madison, Madison, Wisconsin, USA. Nicole Maloney is an alumna of the Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Nicole Maloney
- Leigh Senderowicz is Health Disparities Research Scholar, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, Wisconsin, USA and Postdoctoral Affiliate, Center for Demography and Ecology, University of Wisconsin-Madison, Madison, Wisconsin, USA. Nicole Maloney is an alumna of the Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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13
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Haakenstad A, Angelino O, Irvine CMS, Bhutta ZA, Bienhoff K, Bintz C, Causey K, Dirac MA, Fullman N, Gakidou E, Glucksman T, Hay SI, Henry NJ, Martopullo I, Mokdad AH, Mumford JE, Lim SS, Murray CJL, Lozano R. Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2022; 400:295-327. [PMID: 35871816 PMCID: PMC9304984 DOI: 10.1016/s0140-6736(22)00936-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Meeting the contraceptive needs of women of reproductive age is beneficial for the health of women and children, and the economic and social empowerment of women. Higher rates of contraceptive coverage have been linked to the availability of a more diverse range of contraceptive methods. We present estimates of the contraceptive prevalence rate (CPR), modern contraceptive prevalence rate (mCPR), demand satisfied, and the method of contraception used for both partnered and unpartnered women for 5-year age groups in 204 countries and territories between 1970 and 2019. METHODS We used 1162 population-based surveys capturing contraceptive use among women between 1970 and 2019, in which women of reproductive age (15-49 years) self-reported their, or their partner's, current use of contraception for family planning purposes. Spatiotemporal Gaussian process regression was used to generate estimates of the CPR, mCPR, demand satisfied, and method mix by age and marital status. We assessed how age-specific mCPR and demand satisfied changed with the Socio-demographic Index (SDI), a measure of social and economic development, using the meta-regression Bayesian, regularised, trimmed method from the Global Burden of Diseases, Injuries, and Risk Factors Study. FINDINGS In 2019, 162·9 million (95% uncertainty interval [UI] 155·6-170·2) women had unmet need for contraception, of whom 29·3% (27·9-30·6) resided in sub-Saharan Africa and 27·2% (24·4-30·3) resided in south Asia. Women aged 15-19 years (64·8% [62·9-66·7]) and 20-24 years (71·9% [68·9-74·2]) had the lowest rates of demand satisfied, with 43·2 million (95% UI 39·3-48·0) women aged 15-24 years with unmet need in 2019. The mCPR and demand satisfied among women aged 15-19 years were substantially lower than among women aged 20-49 years at SDI values below 60 (on a 0-100 scale), but began to equalise as SDI increased above 60. Between 1970 and 2019, the global mCPR increased by 20·1 percentage points (95% UI 18·7-21·6). During this time, traditional methods declined as a proportion of all contraceptive methods, whereas the use of implants, injections, female sterilisation, and condoms increased. Method mix differs substantially depending on age and geography, with the share of female sterilisation increasing with age and comprising more than 50% of methods in use in south Asia. In 28 countries, one method was used by more than 50% of users in 2019. INTERPRETATION The dominance of one contraceptive method in some locations raises the question of whether family planning policies should aim to expand method mix or invest in making existing methods more accessible. Lower rates of demand satisfied among women aged 15-24 years are also concerning because unintended pregnancies before age 25 years can forestall or eliminate education and employment opportunities that lead to social and economic empowerment. Policy makers should strive to tailor family planning programmes to the preferences of the groups with the most need, while maintaining the programmes used by existing users. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Annie Haakenstad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Olivia Angelino
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Caleb M S Irvine
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, University of Toronto, Toronto, ON, Canada; Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kelly Bienhoff
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Corinne Bintz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kate Causey
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - M Ashworth Dirac
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA; Swedish Family Medicine, First Hill, Seattle, WA, USA
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Thomas Glucksman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Ira Martopullo
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - John Everett Mumford
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Stephen S Lim
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA.
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14
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Speizer IS, Bremner J, Farid S. Language and Measurement of Contraceptive Need and Making These Indicators More Meaningful for Measuring Fertility Intentions of Women and Girls. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100450. [PMID: 35294385 PMCID: PMC8885354 DOI: 10.9745/ghsp-d-21-00450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 01/05/2022] [Indexed: 11/17/2022]
Abstract
We examine current “need”-based family planning measures that are based on women’s fertility desires and contraceptive use, identify challenges with language and use of need-based measures, and recommend ways to improve language and measurement.
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Affiliation(s)
- Ilene S Speizer
- Department of Maternal and Child Health and Carolina Population Center, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.
| | | | - Shiza Farid
- FP2030, Washington DC, USA
- Avenir Health, Washington, DC, USA
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15
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Farid S, Bremner J, Anderson E. No one left behind: has the pursuit of FP2020's 120 million additional users goal left some women behind? Gates Open Res 2022; 5:114. [PMID: 37564099 PMCID: PMC10409982 DOI: 10.12688/gatesopenres.13339.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 08/12/2023] Open
Abstract
Background: An important question is whether the FP2020's "120 million additional users" goal exacerbated inequities and led to a prioritization of populations within countries where substantial gains towards the goal could be made. We examine FP2020 country data for signs of inequity in gains in modern contraceptive prevalence (MCP). Methods: We selected 11 countries (Bangladesh, Burundi, Ethiopia, Haiti, Malawi, Mali, Nepal, Pakistan, Senegal, Sierra Leone, Uganda, and Zimbabwe) to conduct a bivariate analysis. We evaluated if MCP growth had been equitable by assessing MCP between two surveys stratified by residence, levels of education, age groups, marital status, and wealth. Results: In most countries, MCP increased among rural women and in seven African countries these gains were significant. In six countries, MCP gains were significant both among women with no education and in the lowest wealth group. MCP gains among young women aged 15-19 and 20-24 were seen in four African countries: Malawi, Senegal, Sierra Leone, and Uganda. Conclusions: Our findings suggest that between two surveys since 2010 many countries saw MCP gains across different dimensions of equity and do not suggest a focus on expanded coverage at the expense of equity. As the family planning community begins to look ahead to the next partnership, this analysis can help inform the emerging FP2030 framework, which includes equity as a guiding principle.
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16
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Rothschild CW, Richardson BA, Guthrie BL, Kithao P, Omurwa T, Mukabi J, Callegari LS, Lokken EL, John-Stewart G, Unger JA, Kinuthia J, Drake AL. Contributions of side effects to contraceptive discontinuation and method switch among Kenyan women: a prospective cohort study. BJOG 2021; 129:926-937. [PMID: 34839583 PMCID: PMC9035040 DOI: 10.1111/1471-0528.17032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the contribution of specific contraceptive side effects to method switch and modern-method discontinuation among Kenyan women. DESIGN A prospective cohort study. SETTING Five counties in Western Kenya. PARTICIPANTS Women aged ≥18 years old and emancipated female minors ≥14 years old using modern, reversible contraception were recruited while attending 10 public health facilities. METHODS Patient-reported side effect symptoms, method switch, and discontinuation were reported through weekly text message-based surveys for 24 weeks. MAIN OUTCOME MEASUREMENTS Prevalence, hazards ratio (HR). RESULTS Among 825 women, 44% were using implants, 43% injectables, 7% intrauterine device, and 6% oral contraceptive pills at enrollment. Most (61%) women were continuing a method used in the previous month. During the 24-week follow-up, incidence of contraceptive switch was 61.3 per 100 person-years (95% confidence interval [CI] 52.4-71.8) and incidence of discontinuation was 38.5 per 100 person-years (95%CI 31.6-47.0). On average, one-quarter (prevalence [Pr] 0.24, 95%CI 0.22-0.26) of participants reported side effects or method problems weekly, with sexual side effects the most prevalent symptom (Pr 0.15, 95%CI 0.13-0.16). Lack of expected bleeding was associated with higher risk of method switch (adjusted hazard ratio [aHR] 2.36, 95%CI 1.22-4.57). Risk of all-modern method discontinuation was higher among women experiencing irregular bleeding (adjusted hazard ratio [aHR] 2.39, 95%CI 1.20-4.77), weight changes (aHR 2.72, 95%CI 1.47-4.68), and sexual side effects (aHR 2.42, 95%CI 1.40-4.20). CONCLUSIONS Addressing irregular bleeding, weight changes, and sexual side effects through development of new products that minimize these specific side effects and anticipatory counseling may reduce method-related discontinuation.
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Affiliation(s)
| | - Barbra A Richardson
- Departments of Biostatistics and Global Health, University of Washington, Seattle, USA, Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Brandon L Guthrie
- Departments of Global Health and Epidemiology, University of Washington, Seattle, USA
| | | | | | | | - Lisa S Callegari
- Departments of Obstetrics & Gynecology and Health Services, University of Washington, Seattle, USA
| | - Erica L Lokken
- Department of Global Health, University of Washington, Seattle, USA
| | - Grace John-Stewart
- Departments of Global Health, Epidemiology, Medicine, and Pediatrics, University of Washington, Seattle, USA
| | - Jennifer A Unger
- Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L Drake
- Department of Global Health, University of Washington, Seattle, USA
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17
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Nickels LM, Shane K, Vahdat HL. Catalyzing momentum in male contraceptive development. Biol Reprod 2021; 106:1-3. [PMID: 34739040 PMCID: PMC8757636 DOI: 10.1093/biolre/ioab208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/14/2022] Open
Abstract
Globally, nearly half of all pregnancies are unplanned. Male contraceptives offer the potential to decrease unintended pregnancy and introduce contraceptive equity, but decades of research have yet to bring a novel product to market. New funding avenues from the philanthropic sector seek to stimulate research in male contraceptives through investments, grants, and support for trainees alongside other programs that encourage product development and ultimately commercialization. This Forum outlines the purpose of and funding opportunities provided by Male Contraceptive Initiative, a funding agency and non-profit focused on the advancement of non-hormonal, reversible contraceptive technologies for those who produce sperm.
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18
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Rothschild CW, Brown W, Drake AL. Incorporating Method Dissatisfaction into Unmet Need for Contraception: Implications for Measurement and Impact. Stud Fam Plann 2021; 52:95-102. [PMID: 33595116 PMCID: PMC8048066 DOI: 10.1111/sifp.12146] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
While unmet need for contraception is commonly used to assess programmatic needs, it inadequately captures the complexity of fertility and contraceptive preferences, including women's satisfaction with their contraceptive method. In their 2019 commentary, Sarah Rominski and Rob Stephenson propose reclassifying dissatisfied current users as having an unmet need for contraception. As revising the current definition based on their proposal would require significant investment to update survey and monitoring systems, understanding the potential impact on current estimates of unmet need is critical. We estimated the impact of this approach in a Kenyan cohort of modern contraceptive users. We found the prevalence of method dissatisfaction ranges from 6.6% (95% confidence interval [CI] 5.6–7.8%) to 18.9% (95% CI 17.1–20.9%); if applied nationally, this results in a large (approximately 25–70%) increase in Kenya's current estimate of unmet need for any contraception. Our findings suggest a large impact on unmet need estimates for equivalent populations. Overall, we advocate for better measurements of method satisfaction and acceptability, with metrics developed that are robust to socioeconomic gradients and validated in low‐ and middle‐income settings to ensure women's contraceptive needs are captured equitably.
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Affiliation(s)
- Claire W Rothschild
- Claire W. Rothschild, Department of Epidemiology, University of Washington, Seattle, USA
| | - Win Brown
- Win Brown, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Alison L Drake
- Alison L. Drake, Department of Global Health, University of Washington, Seattle, USA
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