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Lassi ZS, Rahim KA, Stavropoulos AM, Ryan LM, Tyagi J, Adewale B, Kurji J, Bhaumik S, Meherali S, Ali M. Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:195-211. [PMID: 38479786 PMCID: PMC11287556 DOI: 10.1136/bmjsrh-2023-202151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/19/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION The evidence on adolescent empowerment, which involves access to personal and material resources for reproductive autonomy and economic equity, is limited. This systematic review assesses the use of contraceptives in empowering and strengthening the agency and vice versa among adolescents and young women. METHODS We ran the searches in six electronic databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), The Campbell Library, MEDLINE (PubMed), EMBASE, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. The methodological quality of studies was assessed using ROBINS-I and ROB-II tools as appropriate. Meta-analysis was performed using Review Manager 5.4. RESULTS Forty studies that assessed the impact of empowerment on contraceptive use were included. Of these, 14 were non-randomised studies for intervention (NRSIs), and the remaining 26 were randomised controlled trials (RCTs). The results from RCTs show a significant effect of the sexual and reproductive health empowerment in increasing ever use of contraception (RR 1.22; 95% CI 1.02, 1.45; n=9; I²=77%; GRADE: Very Low), and insignificant effect on unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; I²=86%; GRADE: Very Low) and adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; I²=36%; GRADE: Very Low). None of the studies assessed impact of contraceptive use on empowerment. CONCLUSIONS Empowerment of adolescents and young women certainly improves contraceptive use in the immediate or short-term period. However, more robust studies with low risk of bias, longer-term outcomes, and impact of contraceptive use on empowerment and agency-strengthening are required. To increase contraceptive use uptake, tailored policies and delivery platforms are necessary for youth in low- and middle-income countries.
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Affiliation(s)
- Zohra S Lassi
- School of public health, Faculty of health and medical sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Komal Abdul Rahim
- Dean's Office, Medical College, Aga Khan University, Karachi, Pakistan
- Center of Excellence in Trauma and Emergencies, Aga Khan University, Karachi, Pakistan
| | | | - Lareesa Marie Ryan
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Jyoti Tyagi
- George Institute of Global Health, New Delhi, India
| | - Bisi Adewale
- University of Alberta, Edmonton, Alberta, Canada
| | - Jaameeta Kurji
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Soumyadeep Bhaumik
- Meta-Research and Evidence Synthesis Unit, Health Systems Science, George Institute of Global Health, New Delhi, India
- George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales (UNSW Sydney), Sydney, New South Wales, Australia
| | | | - Moazzam Ali
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
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Hellwig F, Wado Y, Barros AJD. Association between women's empowerment and demand for family planning satisfied among Christians and Muslims in multireligious African countries. BMJ Glob Health 2024; 9:e013651. [PMID: 38724069 PMCID: PMC11085792 DOI: 10.1136/bmjgh-2023-013651] [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: 08/07/2023] [Accepted: 02/21/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Although the levels of demand for family planning satisfied (DFPS) have increased in many countries, cultural norms remain a significant barrier in low- and middle-income countries. In the context of multireligious African countries, our objective was to investigate intersectional inequalities in DFPS by modern or traditional contraceptives according to religion and women's empowerment. METHODS Analyses were based on Demographic and Health Surveys carried out between 2010 and 2021 in African countries. Countries with at least 10% of Muslims and Christians were selected to analyse inequalities in family planning. The religious groups were characterised by wealth, area of residence, women's age and women's empowerment. The mean level of empowerment was estimated for each religious group, and multilevel Poisson regression was used to assess whether DFPS varied based on the level of women's empowerment among Muslims and Christians. RESULTS Our study sample of 14 countries comprised 35% of Muslim and 61% of Christian women. Christians had higher levels of empowerment across all three domains compared with Muslims and women with no/other religion. DFPS was also higher among Christians (57%) than among Muslims (36%). Pooled analysis indicated a consistent association between DFPS and women's empowerment, with higher prevalence ratios among Muslims than Christians, especially in the decision-making domain. CONCLUSIONS The gap between Muslims and Christians in DFPS significantly reduced as the level of empowerment increased. It highlights the importance of understanding and addressing cultural factors sensibly and respectfully to satisfy the demand for family planning services.
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Affiliation(s)
- Franciele Hellwig
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Posgraduate Program of Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Yohannes Wado
- African Population and Health Research Center, Nairobi, Kenya
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Posgraduate Program of Epidemiology, Federal University of Pelotas, Pelotas, Brazil
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Holt K, Challa S, Alitubeera P, Atuyambe L, Dehlendorf C, Galavotti C, Idiodi I, Jegede A, Omoluabi E, Waiswa P, Upadhyay U. Conceptualizing Contraceptive Agency: A Critical Step to Enable Human Rights-Based Family Planning Programs and Measurement. GLOBAL HEALTH, SCIENCE AND PRACTICE 2024; 12:e2300299. [PMID: 38346841 PMCID: PMC10906552 DOI: 10.9745/ghsp-d-23-00299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/23/2024] [Indexed: 03/01/2024]
Abstract
We propose a detailed framework for contraceptive agency to serve as a rights-based guide for centering individuals’ ability to make and act on their own contraceptive choices, regardless of what those choices are, in program design and evaluation.
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Affiliation(s)
- Kelsey Holt
- University of California, San Francisco, San Francisco, CA, USA.
| | - Sneha Challa
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Lynn Atuyambe
- Makerere University School of Public Health, Kampala, Uganda
| | | | | | | | | | | | - Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda
| | - Ushma Upadhyay
- University of California, San Francisco, San Francisco, CA, USA
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Sedlander E, Dahal M, Bingenheimer JB, Puri MC, Rimal RN, Granovsky R, Diamond-Smith NG. Adapting and Validating the G-NORM (Gender Norms Scale) in Nepal: An Examination of How Gender Norms Are Associated with Agency and Reproductive Health Outcomes. Stud Fam Plann 2023; 54:181-200. [PMID: 36715570 DOI: 10.1111/sifp.12231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Research calls for the sexual and reproductive rights field to prioritize gender norms to ensure that women can act on their reproductive rights. However, there is a gap in accepted measures. We addressed this by including important theoretical components of gender norms: differentiating between descriptive and injunctive norms and adding a referent group. Our team originally developed and validated the G-NORM, a gender norms scale, in India. In this paper, we describe how we subsequently adapted and validated it in Nepal. We administered items to women of reproductive age, conducted exploratory and confirmatory factor analysis, and examined associations between the subscales and reproductive health outcomes. Like the original G-NORM, our factor analyses showed that descriptive norms and injunctive norms comprise two distinct scales which fit the data well and had Cronbach alphas of 0.92 and 0.89. More equitable descriptive gender norms were associated with higher decision-making scores, increased odds of intending to use family planning, disagreeing that it is wrong to use family planning, and older ideal age at marriage. Injunctive gender norms were only associated with disagreeing that it is wrong to use family planning. Findings offer an improved measure of gender norms in Nepal and provide evidence that gender norms are critical for agency and reproductive health outcomes.
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Affiliation(s)
- Erica Sedlander
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Minakshi Dahal
- Center for Research on Environment, Health & Population Activities, Kathmandu, Nepal
| | | | - Mahesh C Puri
- Center for Research on Environment, Health & Population Activities, Kathmandu, Nepal
| | - Rajiv N Rimal
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Rachel Granovsky
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Nadia G Diamond-Smith
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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Abdullah M, Bilal F, Khan R, Ahmed A, Khawaja AA, Sultan F, Khan AA. Raising the contraceptive prevalence rate to 50% by 2025 in Pakistan: an analysis of number of users and service delivery channels. Health Res Policy Syst 2023; 21:4. [PMID: 36635736 PMCID: PMC9835216 DOI: 10.1186/s12961-022-00950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/17/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Pakistan is the fifth most populous country in the world, with a population that is growing at 2.4% annually. Despite considerable political will, including a national commitment that was endorsed by the president to raise the contraceptive prevalence rate (CPR) to 50% by 2025, it has stagnated at around 30-35%. Much of the dialogue on raising CPR is hypothetical and revolves around percentage point change rather than an actual number of women that must be served. METHODS The Demographic and Health Survey 2017-18 (DHS 2017-18) provides information about the channels through which users receive family planning (FP) services and disaggregates this information at the provincial level. Proportions of users from each of these channels were multiplied by the Pakistan Census-2017 populations to arrive at the number of users. These users were compared with the total FP users and the number of women that had used any FP service in the past 12 months. Linear estimations of population were applied to calculate population numbers in 2025. RESULTS The national target of 50% CPR by 2025 translates to a population of 20.02 million users. Currently, 11.26 million married women of reproductive age (MWRA) use any method, 8.22 million use a modern method and 4.94 million received this service in the past 12 months. Of these, 2.7 million did so from social marketing outlets, 0.76 million from public sector outreach through lady health workers (LHWs), 0.55 million from private sector and 0.88 million from public sector facilities. However, arriving at the CPR target means expanding annual service delivery from 4.94 to 13.7 million users. Since social marketing and LHW outreach may have become saturated, only public and private health facilities are the likely channels for such an expansion. CONCLUSIONS We demonstrate triangulation of the survey data with the census data as a simple policy analysis tool that can help decision-makers estimate the quantum of services they must provide. Such an analysis also allows an understanding of the utilization patterns of each of these channels. In Pakistan's context, underutilization of funds and existing facilities suggests that increased funding or more providers will likely not be helpful. The policy changes that will likely be most effective include adding outreach to support existing public and private sector facilities while ensuring that procurement of commodities is prioritized.
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Affiliation(s)
| | - Faiq Bilal
- Research and Development Solutions, Islamabad, Pakistan
| | - Romesa Khan
- Research and Development Solutions, Islamabad, Pakistan
| | - Azadeh Ahmed
- Research and Development Solutions, Islamabad, Pakistan
| | - Aamir Ashraf Khawaja
- grid.490694.6Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
| | - Faisal Sultan
- grid.490694.6Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan ,grid.415662.20000 0004 0607 9952Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
| | - Adnan Ahmad Khan
- Research and Development Solutions, Islamabad, Pakistan ,grid.490694.6Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
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Ali G, Porter Erlank C, Birhanu F, Stanley M, Chirwa J, Kachale F, Gunda A. Perspectives on DMPA-SC for self-injection among adolescents with unmet need for contraception in Malawi. Front Glob Womens Health 2023; 4:1059408. [PMID: 37034400 PMCID: PMC10073669 DOI: 10.3389/fgwh.2023.1059408] [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] [Received: 10/01/2022] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Malawi has made progress in expanding access to modern contraceptive methods over the last decade, including the introduction of depot-medroxyprogesterone acetate subcutaneous (DMPA-SC) in 2018. DMPA-SC offers women the option to self-inject at home and may benefit adolescents with unmet need for contraception due to its discretion. This qualitative study was conducted to assess perspectives and preferences of adolescents with unmet need for contraception regarding the self-injection option of DMPA-SC in Malawi. Methods Six focus group discussions were conducted involving 36 adolescents with unmet need for contraception (aged between 15 and 19 years, married and never-married) in October 2021 in three districts in Malawi. Data were coded inductively and analyzed thematically, using Dedoose software. Two validation workshops were conducted with other adolescents with unmet need in February 2022 to elucidate the preliminary findings. Results DMPA-SC attributes such as discretion and reduced facility visits were ranked most appealing by both married and never-married adolescents, particularly for adolescents needing covert contraception use. Concerns about self-injection included fear of pain, injury, and doubt in ability to self-inject. Never-married adolescents had additional concerns around privacy at home if using covertly, and fears of affecting long-term fertility. Overall, health surveillance assistants (community-based healthcare workers) were voted to be the most private, convenient, and affordable sources for potential DMPA-SC self-injection training. Conclusion Self-injection of DMPA-SC may offer an appealing option for adolescents in Malawi, aligning most closely to the needs of married adolescents who may wish to delay or space pregnancies conveniently and discreetly, and who also may face fewer access barriers to receiving self-injection training from health care providers. Access barriers including stigma and concerns about privacy at home for adolescents needing to use contraception covertly would need to be adequately addressed if never-married adolescents were to consider taking up this option.
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Affiliation(s)
- Gracious Ali
- Sexual, Reproductive, Maternal and Newborn Health program, Clinton Health Access Initiative (CHAI) Inc., Lilongwe, Malawi
- Correspondence: Gracious Ali
| | - Chelsey Porter Erlank
- Analytics and Implementation Research Team, Clinton Health Access Initiative (CHAI) Inc., London, United Kingdom
| | - Frehiwot Birhanu
- Sexual, Reproductive, Maternal and Newborn Health program, Clinton Health Access Initiative (CHAI) Inc., Lilongwe, Malawi
| | | | - Jessie Chirwa
- Reproductive Health Directorate, Malawi Ministry of Health, Lilongwe, Malawi
| | - Fannie Kachale
- Reproductive Health Directorate, Malawi Ministry of Health, Lilongwe, Malawi
| | - Andrews Gunda
- Clinton Health Access Initiative (CHAI) Inc., Lilongwe, Malawi
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Kenny L, Lokot M, Bhatia A, Hassan R, Pyror S, Dagadu NA, Aden A, Shariff A, Bacchus LJ, Hossain M, Cislaghi B. Gender norms and family planning amongst pastoralists in Kenya: a qualitative study in Wajir and Mandera. Sex Reprod Health Matters 2022; 30:2135736. [PMID: 36416930 PMCID: PMC9704065 DOI: 10.1080/26410397.2022.2135736] [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: 11/24/2022] Open
Abstract
There is growing recognition among global health practitioners of the importance of rights-based family planning (FP) programming that addresses inequities. Despite Kenya achieving its national FP target, inequities in access and use of modern FP remain, especially amongst marginalised nomadic and semi-nomadic pastoralist communities. Few studies explore norms affecting FP practices amongst nomadic and semi-nomadic pastoralists and how these can influence social and behaviour change (SBC) interventions. We carried out 48 in-depth interviews and 16 focus group discussions with women and men from pastoralist communities in North Eastern Kenya in November 2018. Data were analysed thematically. Results from focus groups and interviews confirmed themes, while allowing differences between the qualitative approaches to emerge. We found that large family size was a descriptive and injunctive norm in both nomadic and semi-nomadic communities. The desire for around 10 children was sustained by religious beliefs and pastoralist ways of living. Despite a desire for large families, maintaining child spacing was encouraged and practised through breastfeeding and sexual abstinence. Most participants viewed modern FP negatively and as something used by "others". However, it was acceptable in order to prevent severe negative health outcomes. Future FP research to inform interventions should continue to consider community fertility preferences and the rationale for these, including norms, religion and power dynamics. Targeted qualitative social norms research could inform multi-component SBC interventions in this context.
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Affiliation(s)
- Leah Kenny
- Research Officer, London School of Hygiene and Tropical Medicine, London, UK
- London School of Economics and Political Science, London, UK
| | - Michelle Lokot
- Assistant Professor, London School of Hygiene and Tropical Medicine, London, UK
| | - Amiya Bhatia
- Assistant Professor, London School of Hygiene and Tropical Medicine, London, UK
| | - Rahma Hassan
- PhD Fellow, University of Nairobi, Nairobi, Kenya
| | - Shannon Pyror
- Family Planning Technical Lead, Save the Children, WashingtonDC, USA
| | | | - Abdullahi Aden
- Programme Manager, Wajir Field Office, Save the Children, Nairobi, Kenya
| | - Abdalla Shariff
- Programme Manager, Mandera Field Office Save the Children, Nairobi, Kenya
| | - Loraine J. Bacchus
- Associate Professor, London School of Hygiene and Tropical Medicine, London, UK
| | - Mazeda Hossain
- Associate Professorial Research Fellow, London School of Hygiene and Tropical Medicine, London, UK
- Honorary Associate Professor, London School of Economics and Political Science, London, UK
| | - Beniamino Cislaghi
- Associate Professor, London School of Hygiene and Tropical Medicine, London, UK
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