Correlates of Contraceptive Use and Health Facility Choice among Young Women in Malawi

Determinants of DMPA-SC self-care/self-injectable contraceptive uptake among modern contraceptive users in Burkina Faso: findings from the 2021 demographic and health survey

Introduction

This study aimed to identify the determinants that influence the use of DMPA-SC/Sayana Press among women who use modern contraceptive methods in Burkina Faso.

Methods

This study used secondary data obtained from the 2021 Burkina Faso Demographic and Health Survey (EDSBF). The dependent variable is the use of DMPA-SC among women aged 15-49 who employ modern contraceptive methods. The descriptive analysis used percentages to describe the study variables. The Pearson chi-square test was used to assess the associations between the explanatory variables and the study variable of interest. Bivariate logistic regression was used to examine the crude odds ratios of each explanatory variable with respect to the dependent variable. The multivariate model was used to determine the net effect of each independent variable on the dependent variable. The significance levels were defined at p < 0.05, with corresponding confidence intervals.

Results

The study revealed significant differences in the use of DMPA-SC according to age, marital status, region of residence, level of education, number of children, and involvement in contraceptive decision-making within the couple. Younger women (aged 15-29 aOR = 2.12, p < 0.001)) and women aged 30-39 (aOR = 1.51, p = 0.02) are also more likely to use DMPA-SC compared to those aged 40-49. Married women or those living with a partner [aOR = 1.93 (1.22, 3.05)] are more likely to use DMPA-SC. Women with 1-3 children are twice as likely to use DMPA-SC as those without children (aOR = 1.97, p = 0.02). Region and Wealth Index were significantly associated with DMPA-SC use. The Boucle du Mouhoun region showed a significantly higher likelihood of DMPA-SC use (aOR = 8.10) and women in the highest wealth group are significantly less likely to use DMPA-SC (aOR = 0.59, p = 0.001).

Conclusion

These results demonstrated the importance of adapting interventions to account for socio-demographic, regional, and cultural differences. This will enable the provision of services to the entire female population in a fair and equitable manner, while also addressing the limitations and enhancing the understanding of the underlying factors influencing the use of DMPA-SC.

Factors influencing contraceptive utilisation among postpartum adolescent mothers: a cross sectional study at China-Uganda friendship hospital

BACKGROUND

Globally, modern contraceptives remain underutilized among postpartum mothers resulting in the rise of short birth intervals. While there are a range of other factors that moderate the uptake of contraceptive services, understanding the significance of their influence is critical in public health programming. This study sought to analyze maternal and health facility factors influencing the utilization of contraceptives among postpartum mothers in urban areas of Uganda.

METHODS

Using a cross-sectional study design, a health facility-based study in urban areas of Kampala was conducted from January to March 2023. A total of 332 women aged between 15 and 22 years were randomly selected for the interviews using semi-structured questionnaires. The data was analyzed using a statistical software program R version 4.1.2. Chi-square and multivariable logistic regression were used to determine factors associated with postpartum contraceptive intake among adolescent mothers.

RESULTS

Overall, 28.3% of contraceptive usage was reported in the current study. The majority of the respondents, 98 (29.52%), were within the age group of 17-18 years, and the unmarried were 255 (76.81%). Factors associated with contraception use were income below UgX 500,000 (OR 4.546; CI 1.785-12,193, p = 0.002), occupation status of housewife and student (OR: 3.526; CI: 1.452-8.812, p = 0.006), distance of less than 5 km from health facility (OR: 2.62; CI 1.97-3.55; p = 0.028), and having a contraceptive preference (OR: 3.526; CI: 1.452-8.812, p = 0.006).

CONCLUSIONS

Contraceptive use is low among adolescent post-partum mothers. Income, occupation status, proximity to a health facility, and preference for a particular contractive method are factors associated with contraceptive use in this study. Understanding attitudes and views regarding contraception use is therefore essential for creating effective interventions, given the detrimental effects of adolescent pregnancy.

Predictors of contraceptive discontinuation in Rwanda: evidence from demographic and health survey 2019-2020

BACKGROUND

Despite advancements, Rwanda continues to face challenges regarding contraceptive discontinuation. The 2019-2020 Rwanda Demographic and Health Survey (DHS) reported a 30% discontinuation rate among women within the first year of use. This study analyses predictors of discontinuation using this DHS data, with the goal of strengthening Rwanda's family planning programs.

METHODS

Data from the 2019-20 Rwanda DHS (14,634 women aged 15-49) was examined. A two-stage sampling design informed the survey. Life table methods and Cox proportional hazard models were used to analyze discontinuation rates, median usage duration across contraceptive methods, and the influence of demographic and other factors.

RESULTS

Results indicated a progressive rise in contraceptive discontinuation over different period: 16.69% at 6 months, 29.29% at 12 months, and 47.21% at 24 months. Pills and male condoms showed higher discontinuation probabilities early on. While injectables and LAM initially showed lower discontinuation, rates rose significantly by the 24th month. Health concerns and side effects were the primary reasons cited for discontinuation. The Cox proportional hazards analysis revealed significant factors influencing discontinuation: contraceptive method, desire for pregnancy, husband's disapproval, access/availability, and the desire for a more effective method.

CONCLUSION

This study highlights substantial contraceptive discontinuation rates in Rwanda, particularly for pills and injectables. Method type, health concerns, side effects, and method failure were associated with discontinuation. Interventions should focus on improving contraceptive continuation and investigating alternative methods with lower discontinuation tendencies.

Mobile programs in family planning

PURPOSE OF REVIEW

Mobile health outreach programs are an alternative way to provide family planning services for rural populations or populations affected by conflict, outbreaks, or humanitarian crises. Here, we review the current literature about mobile health outreach programs in family planning.

RECENT FINDINGS

Mobile health outreach programs are effective in delivering family planning services by increasing access to family planning services including expanding method choice, contributing to resilient healthcare models, and advancing reproductive justice.Mobile health outreach programs may be a reasonable, cost saving, person-centered alternative to delivering healthcare particularly when traditional systems are strained.

SUMMARY

Mobile health outreach programs in family planning exist in the United States and globally. Current literature suggests that mobile and outreach programs are effective in increasing knowledge and access to family planning in part by expanding method choice. A mobile health outreach approach is a resilient model that is person-centered and lends itself well to empower patients to practice self-care. The findings and lessons learned may be helpful in guiding future mobile health outreach programs in family planning and other services conducive to an out of clinic model, particularly as a response to overburdened health systems.

Factors associated with continuation of hormonal contraceptives among married women of reproductive age in Gilgit, Pakistan: a community-based case-control study

OBJECTIVE

This study aimed to determine the factors associated with continuation of hormonal contraceptive methods among married women of Gilgit, Pakistan at least 6 months after their initiation.

DESIGN

Unmatched case-control study.

SETTING

Community settings of Gilgit, Pakistan from 1 April 2021 to 30 July 2021.

PARTICIPANTS

The cases were married women of reproductive age who, at the time of interview, were using a hormonal method of contraception for at least 6 months continuously, and controls were married women of reproductive age who had used a hormonal method in the past and currently were using a non-hormonal method for at least 6 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

OR for continuation of hormonal contraceptive.

RESULTS

The factors significantly associated with continuous use of hormonal contraceptive methods for our sample from Gilgit were the family planning centre's distance from home (adjusted OR (AOR) 6.33, 95% CI 3.74 to 10.71), satisfaction with current method used (AOR 3.64, 95% CI 2.06 to 6.44), visits to the family planning centre to avail services (AOR 1.86, 95% CI 1.07 to 3.45) and relatively older age of women (AOR 1.07, 95% CI 1.02 to 1.12). In addition, women with formal education (AOR 0.27, 95% CI 0.12 to 0.6) were less likely to use a modern contraceptive method.

CONCLUSION

Continuation of using a hormonal method was associated with easy access to family planning centres, satisfaction with the current method and frequent visits to the family planning centres. Continuation of using a hormonal method was also seen in women with low education status. The importance of the presence of family planning centres near residential areas cannot be emphasised more. This does not only provide easy access to family planning methods, but also reassure women of continuation of modern methods when they face any unpleasant effects while using these.

Pregnancy and pregnancy intention after experiencing infertility: A longitudinal study of women in Malawi

BACKGROUND

Infertility is a common experience among individuals and couples. Infertility may resolve without intervention, but little is known about pregnancy intentions and incidence of pregnancy following infertility, particularly in low-resource settings.

METHODS

Data come from UTHA, a longitudinal cohort study in Central Malawi, with baseline and follow up surveys conducted from 2014-2019 (N = 1,030 reproductive-aged women). We assessed bivariable and multivariable relationships between reported infertility at baseline and subsequent pregnancy and retrospective pregnancy intentions. Pregnancy intention was measured with the London Measure of Unplanned Pregnancy (LMUP), a scale validated in Malawi (Range = 0-12).

RESULTS

Approximately 20% of the sample reported that they had ever experienced infertility (tried to become pregnant for at least two years without conceiving in that time) at baseline. The proportion of women who reported a new pregnancy during the follow up period (mean = 4.3 years) was the same (65%) for women who had and had not experienced infertility. Among women who became pregnant, levels of pregnancy intendedness were similar between women who had and had not experienced infertility. Prospective desire for a/another child at baseline was associated with subsequent pregnancy (AOR: 1.59; 95%CI: 1.06-2.39) and was also associated with higher levels of pregnancy intendedness measured retrospectively (LMUP of 9.4 vs. 8.4).

CONCLUSIONS

Experienced infertility was not associated with differential odds of having a subsequent pregnancy or the intendedness of a subsequent pregnancy. Thus, women who have experienced infertility should be included in family planning programs and research to support all women in achieving their reproductive goals.

'In fact, that's when I stopped using contraception': a qualitative study exploring women's experiences of using contraceptive methods in KwaZulu-Natal, South Africa

OBJECTIVES

This study explored women's experiences of using contraceptive methods in KwaZulu-Natal, South Africa.

SETTING

In October 2021, we conducted a qualitative study at Umlazi Township in KwaZulu-Natal province, South Africa, through face-to-face in-depth interviews.

PARTICIPANTS

Women from four primary healthcare facilities were recruited through a criterion-based sampling strategy. Using NVivo V.11, two skilled researchers independently conducted thematic data analysis, as a mechanism for quality assurance, before the results were collated and reconciled.

RESULTS

The study included 15 female participants, aged between 18 and 35 years, of whom two-thirds were aged 18-24 years. We found that women were concerned about unpleasant contraceptive methods side effects such as prolonged or irregular menstrual periods, bleeding, weight gain and/or severe pains, resulting in discontinuation of their use. In addition to contraceptive stockouts, women indicated that healthcare providers did not appropriately counsel or inform them about the available contraceptive methods, including how to use them. Key themes included the following: negative effects of contraceptive methods; stockouts of preferred contraceptive methods; inconsistent or incorrect use of contraceptive methods; lack of counselling regarding contracepive methods; and misconceptions about contraception.

CONCLUSIONS

Interventions aimed at reducing contraceptive stockouts are required to ensure that women are empowered to choose contraception based on their own preference, convenience and/or experience. It is imperative that counselling on contraceptive methods' side effects be improved, to ensure that women have freedom to make informed decisions about their preferred method, proper management of side effects and to assist them with method switching as needed, instead of discontinuation.

Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013-2014 facility data and Demographic and Health Survey 2015-2016 individual data in Malawi

OBJECTIVES

Despite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population.

DESIGN AND SETTING

Retrospective cross-sectional analysis of facility data from the 2013-2014 Malawi Service Provision Assessment and individual data from the 2015-2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models.

PARTICIPANTS

2740 children aged 12-23 months living in rural areas.

OUTCOME MEASURES

Immunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout.

FINDINGS

72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37).

CONCLUSION

Proximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.

The aggregate effect of implementation strength of family planning programs on modern contraceptive use at the health systems level in rural Malawi

To explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility's catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve. We used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength. Metrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.

Messages around contraceptive use and implications in rural Malawi

The unmet need for contraception in Malawi remains high, despite progress increasing knowledge and access over the past two decades. Understanding the reasons for this unmet need is critical to programme planning and service delivery. In this study, we conducted 30 in-depth interviews and 13 focus group discussions with women and men in rural Malawi to understand social, cultural and relational barriers and facilitators to contraceptive use. We found that contraceptive decisions were influenced by complex, often conflicting messages with varying implications based on individual and contextual factors. Common factors that influence contraceptive use, such as spousal support, side effects and social norms that dictated acceptable users of contraception could act as both barriers and facilitators to use depending on context. While strides have been made in increasing access to contraception, findings indicate a need for public health programmes to take a nuanced approach to increasing contraceptive use that does not presume particular factors will be a barrier or facilitator across groups. Instead, programmes should seek to understand how social, cultural and relational factors influencing contraceptive use differ across groups.

Faith-based provision of sexual and reproductive healthcare in Malawi

Faith-based organisations constitute the second largest healthcare providers in Sub-Saharan Africa but their religious values might be in conflict with providing some sexual and reproductive health services. We undertake regression analysis on data detailing client-provider interactions from a facility census in Malawi and examine whether religious ownership of facilities is associated with the degree of adherence to family planning guidelines. We find that faith-based organisations offer fewer services related to the investigation and prevention of sexually transmitted infections (STIs) and the promotion of condom use. The estimates are robust to several sensitivity checks on the impact of client selection. Given the prevalence of faith-based facilities in Sub-Saharan Africa, our results suggest that populations across the region may be at risk from inadequate sexual and reproductive healthcare provision which could exacerbate the incidence of STIs, such as HIV/AIDS, and unplanned pregnancies.

Communication, social norms, and contraceptive use among adolescent girls and young women in Lilongwe, Malawi

In Malawi, 50% of adolescent girls and young women (AGYW) have had a first child by age 19 and 45% report their pregnancies as unintended or mistimed. Yet, uptake of contraception remains low. Understanding how interactions with social ties impact AGYW contraceptive use might explain low uptake beyond individual and environmental factors. Data are from Girl-Power, a study among sexually active AGYW, aged 15-24, in Malawi. We used logistic regression models to examine whether contraceptive communication and social norms (descriptive and injunctive) were associated with contraceptive use (non-barrier methods and condoms) and how associations differed across social ties (older women in the family, peers, and partners). The sample included 942 participants: 28% reported using non-barrier methods and 66% reported using condoms. Contraceptive communication with older women in the family (aOR: 1.48, 95% CI: 0.99, 2.20), peers (aOR: 3.12, 95% CI: 1.96, 4.96), and partners (aOR 5.15, 95% CI: 3.13, 8.48) was associated with non-barrier method use. Descriptive norms were associated with non-barrier methods among peers (aOR 2.57, 95% CI: 1.63, 4.96) but not among older women in the family (aOR: 1.22, 95% CI 0.80, 1.88). There were no associations among contraceptive communication, social norms, and condom use across older women in the family, peers, and partners. The findings highlight the need to consider the influence of social ties in the design of future family planning interventions and suggest that interventions that encourage interpersonal communication about contraception and target peer-based descriptive norms have the potential to impact uptake of non-barrier methods.

Infertility, Perceived Certainty of Pregnancy, and Contraceptive Use in Malawi

Infertility and unintended pregnancy are dual burdens in Malawi, where 41% of pregnancies are unintended and approximately 20% of people report infertility. Although preventing unintended pregnancy has been a focus in public health, infertility has rarely been explored as a factor that may be associated with contraceptive use. Using cross-sectional survey data (2017-2018; N = 749), we report on the prevalence of and sociodemographic characteristics associated with infertility and certainty of becoming pregnant among women in Malawi. We conducted multivariable logistic regressions examining the relationship between infertility, certainty of becoming pregnant, and contraceptive use. Approximately 16% of women experienced infertility, and three-quarters (78%) were certain they could become pregnant within one year. Women who experienced infertility had lower odds of contraceptive use than women who did not (Adjusted Odds Ratio [AOR]: 0.56; 95% Conficence Interval [CI]: 0.39-0.83). Women who said there was "no chance" or they were "unlikely" to become pregnant also had lower odds of contraceptive use compared to women who were certain they would become pregnant (AOR: 0.30; 95% CI: 0.10-0.92). Our findings indicate that experiences and perceptions surrounding fertility are associated with contraceptive use, underscoring their importance in understanding how people manage their fertility to reach their reproductive goals.

Contraceptive use and needs among adolescent women aged 15-19: Regional and global estimates and projections from 1990 to 2030 from a Bayesian hierarchical modelling study

Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. To quantify the gaps that remain in meeting needs among adolescents, this study provides a harmonised data set and global estimates and projections of family planning indicators for adolescents aged 15–19 years. We compiled a comprehensive dataset of family-planning indicators among women aged 15–19 from 754 nationally representative surveys. We used a Bayesian hierarchical model with country-specific annual trends to estimate contraceptive prevalence and unmet need for family planning, with 95% uncertainty intervals (UIs), for 185 countries, taking into account changes in proportions married or in a union and differences in sexual activity among unmarried women across countries. Among 300 million women aged 15–19 years in 2019, 29.8 million (95% UI 24.6–41.7) use any contraception, and 15.0 million (95% UI 12.1–29.2) have unmet need for family planning. Population growth and the postponement of marriage influence trends in the absolute number of adolescents using contraception or experiencing unmet need. Large gaps remain in meeting family-planning needs among adolescents. The proportion of the need satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 59.2% (95% UI 44.8–67.2) globally among adolescents, lower compared to 75.7% (95% UI 73.2%–78.0%) among all women age 15–49 years. It was less than one half of adolescents in need in Western Asia and Northern Africa (38.7%, 95%UI = 20.9–56.5), Central and Southern Asia (43.5%, 95%UI = 36.6–52.3), and sub-Saharan Africa (45.6%, 95%UI = 42.2–49.0). The main limitations of the study are: (i) the uncertainty surrounding estimates for countries with limited or biased data is large; and (ii) underreporting of contraceptive use and needs is likely, especially among unmarried adolescents.

Young Women's Experiences With Subcutaneous Depot Medroxyprogesterone Acetate: A Secondary Analysis of a One-Year Randomized Trial in Malawi

PURPOSE

The purpose of this study was to compare the effectiveness, safety, and experiences with side effects of self-injected and provider-administered injectable contraception between young (18-24 years) versus older (≥25 years) women.

METHODS

We conducted secondary analysis of data from a 12-month randomized controlled trial in Malawi, where a total of 731 women were randomized to receive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) administered by a provider or be trained to self-inject subcutaneous depot medroxyprogesterone acetate. Data collectors contacted women after the reinjection window at 3, 6, and 9 months to collect data on discontinuation and women's experiences, including adverse events. Twelve months after enrollment or at early discontinuation, women had their final interview, including pregnancy testing. We compared continuation, pregnancy, safety, and side effects among young women versus older women.

RESULTS

Among self-injectors, there were no significant differences found in continuation by age (p = .345) with continuation rates at 12 months of 79% for young women and 69% for older women. Continuation rates were lower for both age groups with provider-administered injections. In the provider-administered group, continuation rates among young women (39%) were lower than among older women (49%) (p = .047). The distribution of reasons for discontinuation did not differ significantly by age for those receiving provider injections (p = .698). However, younger self-injectors were less likely to miss the reinjection window than older self-injectors (p = .011). Age did not significantly influence pregnancy or safety.

CONCLUSIONS

With evidence of potential higher impact on continuation and no safety concerns, we recommend self-injection be added to the contraception options available to young women in low-resource settings.

Unmet Need for Contraception Among Young Married Women in Eastern Ethiopia

Purpose

Addressing the contraceptive needs of young married women is critical to improve their health and well-being. In patriarchal societies, young married women are under intense pressure to demonstrate their fecundity. Therefore, research that specifically address the needs for contraception of young married women have been generally given less emphasis in Ethiopia. This study assessed the extent of unmet needs for contraception and its associated factors among young married women in Eastern Ethiopia.

Methods

A community-based cross-sectional study was conducted among young married women (14–24 years of age) in Eastern Ethiopia. Data were collected using a structured questionnaire. The prevalence ratio (PR) with 95% confidence intervals (CIs) was calculated, and factors associated with unmet needs for contraception were identified using log-binomial regression statistical model.

Results

Among 2933 young women interviewed, the unmet need for contraception was 1014 (34.6%; 95% CI, 32.9%–36.4%). The prevalence of unmet needs for contraception decreased with increased young women’s household decision-making autonomy score (APR= 0. 76; CI=0.62–0.94). Exposure to family planning (FP) information during the last 12 months (APR= 1.24; CI=1.1–1.42), age 18 or more years (APR=1.25; CI=1.04–1.5), multiparty (APR= 1. 9; CI=1.7–2.1) and desire to have 5 children or lesser than 5 children (APR= 1. 2; CI=1.06–1.32) were associated with higher prevalence of unmet needs for contraception.

Conclusion

One-third of married young women had unmet needs for contraception. More efforts to empower women to make decisions that affect their own life and providing appropriate family planning information are necessary to reduce the burden of unmet needs among young married women in rural settings in Ethiopia.

Predictors of contraceptive use among adolescent girls and young women (AGYW) aged 15 to 24 years in South Africa: results from the 2012 national population-based household survey

BACKGROUND

Despite a variety of contraceptives being available for women in South Africa, a considerable number of adolescent girls and young women still face challenges in using them. This paper examines socio-demographic and behavioral predictors of using contraceptives among adolescent girls and young women (AGYW) aged 15 to 24 years.

METHODS

A secondary data analysis was conducted based on the 2012 population-based nationally representative multi-stage stratified cluster randomised household survey. Multivariate backward stepwise logistic regression model was used to examine socio-demographic and behavioural factors independently associated with contraceptive use amongst AGYW aged 15 to 24 years in South Africa.

RESULTS

Out of 1460 AGYW, 78% (CI: 73.9-81.7) reported using some form of contraceptives. In the model, contraceptive use was significantly associated with secondary education [OR = 1.8 (1.2-2.7), p = 0.005], having a sexual partner within 5 years of their age [OR = 1.8 (1.2-2.5), p = 0.002], and sexual debut at age 15 years and older [OR = 2.5 (1.3-4.6), p = 0.006]. The likelihood of association decreased with other race groups-White, Coloured, and Indians/Asians [OR = 0.5 (0.3-0.7), p = 0.001], being married [OR = 0.4 (0.2-0.7), p = 0.001], never given birth [OR = 0.7 (0.5-0.9), p = 0.045], coming from rural informal [OR = 0.5 (0.3-0.9), p = 0.010] and rural formal settlements [OR = 0.5 (0.3-0.9), p = 0.020].

CONCLUSIONS

Evidence suggest that interventions should be tailor-made to meet the needs of AGYW in order to, promote use and access to contraceptives. The results also suggest that family planning interventions should target those who had not given birth in order to reduce unplanned and or unintended pregnancies and associated risk factors. These findings contribute to public health discourse and reproductive health planning for these age groups in the country.

Efficacy of a Digital Health Tool on Contraceptive Ideation and Use in Nigeria: Results of a Cluster-Randomized Control Trial

A mobile digital health tool piloted in Kaduna City, Nigeria, was efficacious in promoting positive contraceptive attitudes and encouraging women to adopt a modern contraceptive method, thus showing potential for reducing unmet need in Nigeria.

Background:

Contraceptive prevalence in Nigeria remains among the lowest in the world, which substantially contributes to the country's high maternal and child mortality. Mobile phone technology penetration has increased considerably in Nigeria, opening opportunities for programs to use this medium for reaching their intended audience with health-protective information.

Methods:

In 2017, the Health Communication Capacity Collaborative conducted a cluster-randomized control trial in Kaduna City to assess the efficacy of the digital health tool Smart Client on ideational and behavioral variables related to family planning. Twelve wards in the city were randomly assigned to intervention (6 wards) and control (6 wards) arms of the study. A total of 565 women aged 18–35 years were randomly selected from study wards and consented to participate in the study. At recruitment, the women completed a baseline survey. The women in the intervention group were registered to receive 1 welcome call, 13 program calls, and 3 quiz calls on their mobile phones. Each of the program calls had several segments, including introduction, drama episode, and friend-to-friend chat. The last quiz call included evaluation questions. Women in the control arm received no intervention. The efficacy of the intervention was assessed using both per-protocol and intent-to-treat differences-in-differences techniques.

Results:

The intervention and control arms were equivalent in terms of key sociodemographic characteristics, with the exception of religion. Attrition was a major challenge in the study. On average, participants receiving the intervention listened to 7.2 drama episodes but only 2.6 personal stories and 1.1 sample dialogues. The results of both per-protocol and intent-to-treat analyses show that the intervention was efficacious in improving relevant ideational and behavioral outcomes. For example, the intent-to-treat results show that the intervention increased women's perceived level of confidence to discuss family planning with a provider by 27.7 percentage points and modern contraceptive prevalence by 14.8 percentage points.

Conclusion:

This efficacy assessment showed that using an interactive voice response-based digital tool that includes drama is a viable option for promoting positive ideation about family planning and increasing contraceptive use in Nigeria. Significant lessons learned from this efficacy trial include informing participants at the time of recruitment of what the opening segment of the calls will sound like to avoid the calls being mistaken for telemarketing calls and intensive testing prior to scale-up to avoid potential attrition due to technical issues.

Individual, community and service environment factors associated with modern contraceptive use in five Sub-Saharan African countries: A multilevel, multinomial analysis using geographically linked data from PMA2020

The importance of the family planning service environment and community-level factors on contraceptive use has long been studied. Few studies, however, have been able to link individual and health facility data from surveys that are nationally representative, concurrently fielded, and geographically linked. Data from Performance Monitoring and Accountability 2020 address these limitations. To assess the relative influences of the service delivery environment and community, household, and individual factors on a woman's likelihood of using a modern contraceptive in five geographically and culturally diverse sub-Saharan African countries. Nationally representative, cross-sectional data from PMA2020 were linked at the household and service delivery level. Country-specific and pooled multilevel multinomial logistic models, comparing non-users, short- and long-acting method users were used. The variables elected for inclusion in our multivariate analyses were guided by the conceptual framework to profile the different levels of influences on individual use of modern contraception. Average marginal effects were calculated to improve interpretability. We find that the effect of contextual factors varies widely but that being visited by a health worker who spoke about family planning in the past 12 months was consistently and positively associated with individual use of short-acting and long-acting contraception. Characteristics of the nearest health facility did not generally exercise their own independent influences on a woman's use of contraception, except in the case of Burkina Faso, where the average distance between individuals and the nearest family planning provider was significantly greater than other countries. Inclusion of country fixed effects in the pooled models and the relevance of covariates at different levels in the country-specific models demonstrate that there is significant variation across countries in how community, individual, and service delivery environment factors influence contraceptive use and method choice. Context must be taken into account when designing family planning programs.

Causal effects of education on sexual and reproductive health in low and middle-income countries: A systematic review and meta-analysis

Background

Despite strong theoretical grounding, important gaps in knowledge remain regarding the degree to which there is a causal relationship between education and sexual and reproductive health, as many claims have been made based on associations alone. Understanding the extent to which these relationships are causal is important both to inform investments in education and health, as well as to understand the mechanisms underlying these relationships.

Methods

We conducted a systematic review of the evidence for a causal link between education and sexual and reproductive health (SRH) in low and middle-income countries. Education indicators included exposure to formal schooling and learning. SRH outcomes included: age at first sex, age at first marriage, age at first pregnancy/birth, contraceptive use, fertility, and HIV status and other sexually transmitted infections. When possible, we also conducted meta-analyses to estimate mean effects by outcome, and to understand sources of variation between studies.

Results

We identified 35 papers that met our inclusion criteria. Although many of the studies report evidence of a causal relationship between education and one or more SRH outcomes, estimated effects are often small in magnitude. Our meta-analyses reveal mostly null mean effects, with the exception of small effects of increased grade attainment on lower fertility and HIV positive status. We also found inconsistent evidence supporting mechanisms linking education and SRH.

Conclusions

This review demonstrates that, although investments in schooling may have positive ripple effects for sexual and reproductive health in some circumstances, those effects may not be as large or consistent as expected. Further, our understanding of the circumstances in which schooling is most likely to improve SRH remains somewhat limited. An accurate picture of whether and when improvements in education lead to better health outcomes is essential for the achievement of global development goals.