Fertility regulation as identity maintenance: Understanding the social aspects of birth control

The association between contraceptive use and desired number of children among sexually active men in Zambia

BACKGROUND

Contraceptive methods have been used to space births, but also to limit a couple's desired number of children. Efforts of family planning programmes have mainly concentrated on females, even though males tend to have large say on the desired number of children a couple should have. In our study, we sought to determine linkages between contraceptive use and desired number of children, as well as associated demographic and socio-economic characteristics, among sexually active males in Zambia.

METHODS

The main outcome variable of interest was desired number of children as measured by ideal number of children which is a count variable. Data for this paper was the male dataset from the 2018 Zambia Demographic and Health Survey, a cross-sectional national survey. Binary logistic regression was performed to determine odds ratios of contraceptive use by selected characteristics of sexually active males. Multivariate Poisson Regression Model was used to establish factors associated with desired number of children.

RESULTS

Age of men (20-29, 30-39 and 40-49 years), residence in rural areas, wealth quintile, Protestant or Muslim religious affiliation, media exposure, and having discussed family planning with a health worker in the last few months prior to the survey were associated with contraceptive use. Sexually active males who reported using any contraception method reported 3% less desired number of children compared to those who were not using any method. Older males (age group 30-49 years), resident in rural areas, with primary education, married, employed, Protestant religion, and those labelling women who use contraceptives "as promiscuous" had more desired number of children.

CONCLUSIONS

There were minimal differences in the desired number of children among males who reported using and not using any contraceptive method. Strategies aimed at encouraging contraception use should cover all categories of males to achieve universal involvement of men in family planning in Zambia. Future research may consider combining both qualitative and quantitative methods to look holistically at the demographic, socio-economic and cultural factors associated with non-contraception use and desired number of children among sexually active men in Zambia.

Urban Family Planning in Low- and Middle-Income Countries: A Critical Scoping Review

Health agendas for low- and middle-income countries (LMICs) should embrace and afford greater priority to urban family planning to help achieve a number of the global Sustainable Development Goals. The urgency of doing so is heightened by emerging evidence of urban fertility stalls and reversals in some sub-Saharan African contexts as well as the significance of natural increase over migration in driving rapid urban growth. Moreover, there is new evidence from evaluations of large programmatic interventions focused on urban family planning that suggest ways to inform future programmes and policies that are adapted to local contexts. We present the key dimensions and challenges of urban growth in LMICs, offer a critical scoping review of recent research findings on urban family planning and fertility dynamics, and highlight priorities for future research.

Use of Fertility Awareness-Based Methods for Pregnancy Prevention Among Ghanaian Women: A Nationally Representative Cross-Sectional Survey

Few studies in low- and middle-income countries have examined the use of fertility awareness-based methods (FABMs) for pregnancy prevention. Understanding the prevalence of FABM use among Ghanaian contraceptors and the characteristics and practices of users is essential. Our 2018 nationally representative survey of Ghanaian women included detailed questions on the use of rhythm and Standard Days Method/Cycle Beads (SDM). After considering multimethod use patterns, we estimated likely FABM prevalence among contraceptors, identified characteristics associated with current use of an FABM (vs. current use of a hormonal method/intrauterine device [IUD]), and described how women report using FABMs. At least 18% of contracepting Ghanaian women likely use an FABM, though this may be underreported. Among FABM users, 57% reported current use of an FABM alone; the remainder reported concurrent use of other methods. Women who were older, richer, more educated, and had fewer children had higher odds of current FABM use versus IUD/hormonal method. Although FABM users were more likely than other contraceptors to correctly identify the approximate fertile time, only 50% of FABM users did so correctly. Most (92%) rhythm users were interested in making their method use more effective. While 72% had heard of SDM, less than 25% had heard of various other ways to make the rhythm method more effective. Only 17% of rhythm users had ever discussed the method with a health professional. Rhythm users indicated substantial willingness to track additional biomarkers (e.g., daily temperature or cervical mucus) or to use a phone to enhance the effectiveness of their method, and most indicated no substantial difficulty getting partners to abstain or withdraw on fertile days. A nontrivial proportion of reproductive age Ghanaian women are using an FABM, nearly all of whom are interested in learning how to improve its effectiveness. The family planning field should better address these women's contraceptive needs in commitment to reproductive autonomy and choice.

Sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa: Evidence from demographic and health surveys

INTRODUCTION

Contraception plays a significant role in fertility regulation and determines the reproductive health rights of women. Studies in other parts of the world have found that sexual violence has negative effects on unmet need for contraception. There has not been any study on the association between these two phenomena in sub-Saharan Africa using current nationally-representative survey data. We investigated the association between sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa.

MATERIALS AND METHODS

This study was based on secondary datasets from 26 sub-Saharan African countries' Demographic and Health Surveys conducted between 2010 and 2018. A sample of 101,968 women in sexual unions (married and cohabiting) with complete information on sexual violence and all the variables of interest were included in the analyses. Both bivariate and multilevel logistic regression analyses were carried out to examine the association between sexual violence and unmet need for contraception. Other individual and contextual level socio-economic and demographic variables were considered as covariates. Crude odds ratios [cOR] and adjusted odds ratios [aOR] with their corresponding 95% confidence intervals [CI], signifying precision, were presented. Level of statistical significance was declared at p<0.05.

RESULTS

The overall prevalence of sexual violence and unmet need for contraception in the 26 sub-Saharan African countries were 8.7% and 28.7% respectively. Experience of sexual violence within the last 12 months resulted in 10% increase in unmet need for contraception [OR = 1.10, CI = 1.03-1.14] and 5% increase in unmet need for contraception after controlling for individual and contextual level factors [aOR = 1.05, CI = 1.01-1.11]. With the individual level factors, women with 4 or more births [aOR = 4.85, CI = 4.41-5.33], those cohabiting [aOR = 1.43, CI = 1.37-1.47], those in female headed households [aOR = 1.22, CI = 1.18-1.27] and those who watched television at least once a week [aOR = 1.12, CI = 1.07-1.16] had higher odds of unmet need for family planning. However, those aged 30-34 [aOR = 0.56, CI = 0.52-0.61], those with secondary/higher level of education [AOR = 0.80, CI = 0.77-0.84], those who read newspaper less than once a week [aOR = 0.75, CI = 0.71-0.79] and those who listened to radio at least once a week [aOR = 0.94, CI = 0.90-0.97] had lower odds of unmet need for contraception. In terms of the contextual factors, women in rural areas [aOR = 0.87, CI = 0.84-0.91] and those in the richest wealth quintile households [aOR = 0.80, CI = 0.75-0.85] had lower odds of unmet need for contraception.

CONCLUSION

Our study has shown an association between sexual violence and unmet need for contraception in sub-Saharan Africa. Experiencing sexual violence increases the likelihood of unmet need for contraception in sub-Saharan Africa. It is also worthy to note that having four or more children, cohabiting with a male partner, and living in female-headed households are some of the key variables associated with unmet need for contraception in sub-Saharan Africa. Our study recommends that, successful contraceptive initiatives should focus on reducing sexual violence, while taking into consideration other significant factors that increase unmet need for contraception. Meanwhile, in doing this, contextual factors ought to be prioritised.

Understanding the health-care experiences of people with sickle cell disorder transitioning from paediatric to adult services: This Sickle Cell Life, a longitudinal qualitative study

Background

Transitions from paediatric to adult health-care services cause problems worldwide, particularly for young people with long-term conditions. Sickle cell disorder brings particular challenges needing urgent action.

Objectives

Understand health-care transitions of young people with sickle cell disorder and how these interact with broader transitions to adulthood to improve services and support.

Methods

We used a longitudinal design in two English cities. Data collection included 80 qualitative interviews with young people (aged 13–21 years) with sickle cell disorder. We conducted 27 one-off interviews and 53 repeat interviews (i.e. interviews conducted two or three times over 18 months) with 48 participants (30 females and 18 males). We additionally interviewed 10 sickle cell disease specialist health-care providers. We used an inductive approach to analysis and co-produced the study with patients and carers.

Results

Key challenges relate to young people’s voices being ignored. Participants reported that their knowledge of sickle cell disorder and their own needs are disregarded in hospital settings, in school and by peers. Outside specialist services, health-care staff refuse to recognise patient expertise, reducing patients’ say in decisions about their own care, particularly during unplanned care in accident and emergency departments and on general hospital wards. Participants told us that in transitioning to adult care they came to realise that sickle cell disorder is poorly understood by non-specialist health-care providers. As a result, participants said that they lack trust in staff’s ability to treat them correctly and that they try to avoid hospital. Participants reported that they try to manage painful episodes at home, knowing that this is risky. Participants described engaging in social silencing (i.e. reluctance to talk about and disclose their condition for fear that others will not listen or will not understand) outside hospital; for instance, they would avoid mentioning cell sickle disorder to explain fatigue. Their self-management tactics include internalising their illness experiences, for instance by concealing pain to protect others from worrying. Participants find that working to stay healthy is difficult to reconcile with developing identities to meet adult life goals. Participants have to engage in relentless self-disciplining when trying to achieve educational goals, yet working hard is incompatible with being a ‘good adult patient’ because it can be risky for health. Participants reported that they struggle to reconcile these conflicting demands.

Limitations

Our findings are derived from interviews with a group of young people in England and reflect what they told us (influenced by how they perceived us). We do not claim to represent all young people with sickle cell disorder.

Conclusions

Our findings reveal poor care for young people with sickle cell disorder outside specialist services. To improve this, it is vital to engage with young people as experts in their own condition, recognise the legitimacy of their voices and train non-specialist hospital staff in sickle cell disorder care. Young people must be supported both in and outside health-care settings to develop identities that can help them to achieve life goals.

Future work

Future work should include research into the understanding and perceptions of sickle cell disease among non-specialist health-care staff to inform future training. Whole-school interventions should be developed and evaluated to increase sickle cell disorder awareness.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 44. See the NIHR Journals Library website for further project information.

Using qualitative evaluation components to help understand context: case study of a family planning intervention with female community health volunteers (FCHVs) in Nepal

BACKGROUND

Evaluations of health interventions are increasingly concerned with measuring or accounting for 'context'. How to do this is still subject to debate and testing, and is particularly important in the case of family planning where outcomes will inevitably be influenced by contextual factors as well as any intervention effects. We conducted an evaluation of an intervention where female community health volunteers (FCHVs) in Nepal were trained to provide better interpersonal communication on family planning. We included a context-orientated qualitative component to the evaluation. Here, we discuss the evaluation findings, specifically focusing on what was added by attending to the context. We explore and illustrate important dimensions of context that may also be relevant in future evaluation work.

METHODS

The evaluation used a mixed methods approach, with a qualitative component which included in-depth interviews with women of reproductive age, FCHVs, and family planning service providers. We conducted iterative, thematic analysis.

RESULTS

The life-history fertility and contraception narratives generated from the in-depth interviews contextualised the intervention, yielding nuanced data on contraceptive choices, needs, and areas for future action. For instance, it highlighted how women generally knew about effective contraceptive methods and were willing to use them: information was not a major barrier. Barriers instead included reports of providers refusing service when women were not in the fifth day of their menstrual cycle when this was unnecessary. Privacy and secrecy were important to some women, and risked being undermined by information sharing between FCHVs and health services. The qualitative component also revealed unanticipated positive effects of our own evaluation strategies: using referral slips seemed to make it easier for women to access contraception.

CONCLUSIONS

Life history narratives collected via in-depth interviews helped us understand pathways from intervention to effect from the user point of view without narrowly focusing only on the intervention, highlighting possible areas for action that would otherwise have been missed. By attending to context in a nuanced way in evaluations, we can build a body of evidence that not only informs future interventions within that context, but also builds better knowledge of contextual factors likely to be important elsewhere.

Transitions to adulthood: self-governance and disciplining in the making of patient citizens

Young people develop new behaviours and redefine their identities during health transitions when they move from paediatric to adult healthcare environments. Their identities help to guide their health-related actions in response to life changes. Young people's health is increasingly recognised as important, yet we lack understanding of how health transitions shape identities and how they relate to other transitions to adulthood. We conducted a longitudinal interview study with young people with sickle cell disease to explore how young people define new identities as they transition to adulthood. We show how 'disciplining at a distance' via healthcare self-management discourses and neoliberal norms governing adolescence play out in the tensions participants encounter when they are crafting new identities. Health transitions involve struggles to negotiate competing demands for self-discipline. It is crucial to create enabling spaces for young people to protect their health while still developing identities that help them achieve life goals.

The maximum contraceptive prevalence 'demand curve': guiding discussions on programmatic investments

Most frameworks for family planning include both access and demand interventions. Understanding how these two are linked and when each should be prioritized is difficult. The maximum contraceptive prevalence ‘demand curve’ was created based on a relationship between the modern contraceptive prevalence rate (mCPR) and mean ideal number of children to allow for a quantitative assessment of the balance between access and demand interventions. The curve represents the maximum mCPR that is likely to be seen given fertility intentions and related norms and constructs that influence contraceptive use. The gap between a country’s mCPR and this maximum is referred to as the ‘potential use gap.’ This concept can be used by countries to prioritize access investments where the gap is large, and discuss implications for future contraceptive use where the gap is small. It is also used within the FP Goals model to ensure mCPR growth from access interventions does not exceed available demand.