Learning from success cases: ecological analysis of potential pathways to universal access to family planning care in low- and middle-income countries

Policies for expanding family planning coverage: lessons from five successful countries

Background

Enhancing the design of family planning interventions is crucial for promoting gender equality and improving maternal and child health outcomes. We identified, critically appraised, and synthesized policies and strategies from five selected countries that successfully increased family planning coverage.

Methods

We conducted a policy analysis through a scoping review and document search, focusing on documents published from 1950 to 2023 that examined or assessed policies aimed at enhancing family planning coverage in Brazil, Ecuador, Egypt, Ethiopia, and Rwanda. A search was conducted through PubMed, SCOPUS, and Web of Science. Government documents and conference proceedings were also critically analyzed. National health surveys were analyzed to estimate time trends in demand for family planning satisfied by modern methods (mDFPS) at the national level and by wealth. Changes in the method mix were also assessed. The findings of the studies were presented in a narrative synthesis.

Findings

We selected 231 studies, in which 196 policies were identified. All countries started to endorse family planning in the 1960s, with the number of identified policies ranging between 21 in Ecuador and 52 in Ethiopia. Most of the policies exclusively targeted women and were related to supplying contraceptives and enhancing the quality of the services. Little focus was found on monitoring and evaluation of the policies implemented.

Conclusion

Among the five selected countries, a multitude of actions were happening simultaneously, each with its own vigor and enthusiasm. Our findings highlight that these five countries were successful in increasing family planning coverage by implementing broader multi-sectoral policies and considering the diverse needs of the population, as well as the specific contextual factors at play. Successful policies require a nuanced consideration of how these policies align with each culture's framework, recognizing that both sociocultural norms and the impact of past public policies shape the current state of family planning.

A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions

Objective

To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status.

Methods

We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index.

Findings

In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population.

Conclusion

The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.