Contraceptive Dynamics in Rural Northern Malawi: A Prospective Longitudinal Study

Contraceptive uses among married women in Bangladesh: a systematic review and meta-analyses

BACKGROUND

Although Bangladesh's economy has shown significant improvement over the past two decades, the high population growth rate has hindered development efforts. This study aimed to review the prevalence of different contraceptive methods used among women of reproductive age in Bangladesh, which could help control the population growth rate.

METHODS

We conducted an extensive literature review and meta-analysis of 82 articles, identifying 20 articles for analysis. The analyses included heterogeneity and publication bias in published papers.

RESULTS

The pooled prevalence of various contraceptive methods was as follows: condom use, 7.13%; Female Sterilization, 8.09%; injectables, 12.76%; intrauterine devices (IUDs), 3.76%; male sterilization, 2.34%; periodic abstinence, 6.71%; pills, 33.21%; and withdrawal, 3.27%. Modern contraceptive methods accounted for 62.91% of usage, while traditional methods constituted 8.79%. On average, only 1.95% of women opted for the implant method. The overall prevalence of contraceptive method usage was 59.48%, with 60.59% in urban areas and 54.54% in rural areas. We found statistically significant heterogeneity for all contraceptive methods used by women in Bangladesh. The funnel plot and Egger's test showed no publication bias for any of the contraceptive methods, except condoms (Z = 2.34, P = 0.0194). The contraceptive methods used by women in rural areas also showed publication bias (Z = -3.04, P = 0.0024).

CONCLUSION

A renewed commitment from government bodies and independent organizations is needed to implement and monitor family planning strategies to ensure adherence to and provision of the most appropriate contraceptive method for couples.

Modeling Contraception and Pregnancy in Malawi: A Thanzi La Onse Mathematical Modeling Study

Malawi has high unmet need for contraception with a costed national plan to increase contraception use. Estimating how such investments might impact future population size in Malawi can help policymakers understand effects and value of policies to increase contraception uptake. We developed a new model of contraception and pregnancy using individual-level data capturing complexities of contraception initiation, switching, discontinuation, and failure by contraception method, accounting for differences by individual characteristics. We modeled contraception scale-up via a population campaign to increase initiation of contraception (Pop) and a postpartum family planning intervention (PPFP). We calibrated the model without new interventions to the UN World Population Prospects 2019 medium variant projection of births for Malawi. Without interventions Malawi's population passes 60 million in 2084; with Pop and PPFP interventions. it peaks below 35 million by 2100. We compare contraception coverage and costs, by method, with and without interventions, from 2023 to 2050. We estimate investments in contraception scale-up correspond to only 0.9 percent of total health expenditure per capita though could result in dramatic reductions of current pressures of very rapid population growth on health services, schools, land, and society, helping Malawi achieve national and global health and development goals.

"I know my body and I just can't get pregnant that easily" - Women's use and non-use of the injection to manage fertility

Approximately one-third of contraceptive users in Malawi use the Depo-Provera injection, a method that must be re-injected every three-months to prevent pregnancy and may reduce fecundity for a time after discontinuation. Little is known about how women use the injection to achieve their desired family size. In 2018, we conducted 20 in-depth interviews with women who were part of a cohort study in rural Malawi. Interviews focused on contraceptive decision-making. Data were indexed (summarized) and coded using narrative, process, and thematic codes. Women described the importance of knowing about their "natural" fertility by having children prior to ever using contraception because women considered contraception to have a potential negative effect on fertility. Women then applied what they learned about their fertility (i.e., how easy/difficult it was to become pregnant) to manage their fertility over their reproductive life-course. As part of fertility management, women frequently described using the injection less frequently than clinically recommended, using signs from their body (e.g., menstruation) to determine when to reinject. Managing fertility through subclinical injection use was viewed as a way to optimize women's' chances of preventing unintended pregnancy while maintaining their ability to become pregnant when they wanted to. Women wanted to play an active role in managing their fertility and were not passive consumers of contraception. It is therefore critical that family planning programs provide contraceptive counseling to women that engages their desire to manage their fertility, acknowledges their concerns about fertility, and helps them choose a method that best fits their needs.

The relationship between client dissatisfaction and contraceptive discontinuation among urban family planning clients in three sub-Saharan African countries

Although researchers and practitioners have suggested that the quality of family planning services impacts contraceptive discontinuation, establishing a causal relationship has been challenging, primarily due to data limitations and a lack of agreement on how to measure quality. This longitudinal study estimated the relationship of the dissatisfaction with family planning services on contraceptive discontinuation for a sample of 797 female clients who sought family planning services at urban facilities across Kenya, Nigeria, and Burkina Faso. Clients who sought family planning services were first interviewed in person at private and public health facilities and received a follow-up phone interview four to six months later. In our sample, 18.2% of clients who were using a modern contraceptive at baseline stopped using it by follow-up. At baseline, nearly 14% of clients reported experiencing a problem with service convenience, nearly 12% with the availability of medicines and contraceptives, and nearly 6% with facility cleanliness and/or staff treatment. We hypothesized that client dissatisfaction with the family planning services received informed their decision to discontinue contraception and estimated univariate and bivariate probit regression models, controlling for individual and health facility characteristics. We found that client’s perceptions of staff treatment and facility cleanliness informed their expectations about service and contraceptive standards, affecting subsequent contraceptive discontinuation. The difference in the probability of discontinuing contraception was 8.2 percentage-points between dissatisfied and satisfied clients. Examining client dissatisfaction with family planning services can inform the family planning community on needed improvements to increase contraceptive adherence for women in need, which can prevent unplanned pregnancies and unwanted births in the long run.

Women’s contraceptive profiles in Burundi: Knowledge, attitudes, and interactions with media and health services

Reproductive health program managers seek information about existing and potential clients’ motivations, behaviors, and barriers to services. Using sequence and cluster analysis of contraceptive calendar data from the 2016–17 Burundi Demographic and Health Survey, we identified discrete clusters characterizing patterns in women’s contraceptive and pregnancy behaviors over the previous 5 years. This study pairs these clusters with data on factors typically targeted in social behavior change interventions: knowledge, attitudes, and women’s interactions with media and health services, to create composite profiles of women in these clusters. Of six clusters, three are characterized by contraceptive use and three are characterized by its absence. Media exposure and attitudes regarding sex preference, wife beating, and self-efficacy largely do not explain cluster membership. Contraceptive knowledge is positively associated with two clusters (Family Builder 1 and Traditional Mother) and negatively associated with a third (Quiet Calendar). Clusters also differ in their members’ fertility desires, contraceptive intentions, and interactions with health services. Two “Family Builder” clusters are both characterized by the presence (but not timing) of multiple pregnancies in their calendar histories, but differ in that women with high contraceptive knowledge, intentions to use contraception, and well-articulated family size ideals are characteristic of one cluster (Family Builder 1), and low contraceptive knowledge, no use of contraception, and vague family size preferences are characteristic of the other (Family Builder 2). These results can guide reproductive health programs as they target social and behavioral change and other interventions to the unique subpopulations they seek to serve.

Family planning providers and contraceptive users in Rwanda employ strategies to prevent discontinuation

BACKGROUND

In Rwanda, nearly a third of contraceptive users discontinue within the first year of use. Family planning programs often focus more on recruitment of new users as opposed to maintaining use among current users. A focus on sustaining users and minimizing discontinuation is imperative for long-term family planning program success. This study explores the efforts providers and contraceptive users in Rwanda employ to prevent one of the greatest challenges to family planning programs: contraceptive discontinuation.

METHODS

This was a qualitative study conducted in Rwanda between February and July 2018. It included eight focus group discussions with 88 family planning providers and 32 in-depth interviews with experienced modern contraceptive users. Data were collected in two districts with the highest (Musanze) and lowest (Nyamasheke) rates of contraceptive use. Data were analyzed using thematic content approach.

RESULTS

Family planning providers in this study used the following strategies to prevent discontinuation: counseling new users on the potential for side effects and switching, reminding clients about appointments for resupply, as well as supporting dissatisfied users by providing counseling, medicine for side effects, and discussing options for switching methods. Users, on the other hand, employed the following strategies to prevent discontinuation: having an understanding that experiences of side effects vary by individuals, supporting peers to sustain use, persisting with use despite experiences of side effects, and switching methods.

CONCLUSIONS

The strategies used by family planning providers and users in Rwanda to prevent discontinuation suggest the possibility of long-term sustained use of contraception in the country. Harnessing and supporting such strategies could contribute to sustaining or improving further contraceptive use in the country.

Service delivery point and individual characteristics associated with the adoption of modern contraceptive: A multi-country longitudinal analysis

Background

Women who start using contraception (“adopters”) are a key population for family planning goals, but little is known about characteristics that predict the adoption of contraception as opposed to current use. We used prospective data from women and facilities for five countries, (Democratic Republic of Congo, India, Kenya, Nigeria, and Burkina Faso) and identified baseline characteristics that predicted adoption of modern contraception in the short term.

Methods

We used data from the Performance Monitoring for Action (PMA) Agile Project. PMA Agile administered service delivery point (SDP) client exit interview (CEI) surveys in urban sites of these five countries. Female clients responding to the CEI were asked for phone numbers that were used for a phone follow-up survey approximately four months later. For our analysis, we used data from the SDP and CEI baseline surveys, and the phone follow up to compare women who start using contraception during this period with those who remain non-users. We used characteristics of the facility and the woman at baseline to predict her contraception adoption in the future.

Results

Discussing FP with a partner at baseline was associated with greater odds of adoption in DRC (OR 2.34; 95% CI 0.97–5.66), India (OR 2.27; 95% CI 1.05–4.93), and Kenya (OR 1.65; 95% CI 1.16–2.35). Women who discussed family planning with any staff member at the health facility had 1.72 greater odds (95% CI 1.13–2.67) of becoming an adopter in Nigeria. The odds of adoption were lower in Nigerian facilities that had a stockout (OR 0.66 95% CI 0.44–1.00) at baseline. Other characteristics associated with contraception adoption across settings were education, age, wealth, parity, and marital status.

Conclusions

Characteristics of both the woman and the health facility were associated with adoption of modern contraception in the future. Some characteristics, like discussing family planning with a spouse, education, and parity, were associated with contraceptive adoption across settings. Other characteristics that predict contraceptive use, such as health facility measures, varied across countries.

Women's perspectives on relationship dynamics with their partners and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use

Background: Limited information exists about relationship dynamics and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use among women in Malawi.Methods: Ninety-seven women aged 18-45 years were randomly assigned to initiate the depot medroxyprogesterone acetate injectable or levonorgestrel implant from May 2014 to April 2015 in Lilongwe, Malawi. Women were recruited after randomisation to participate in semi-structured interviews about HIV and family planning using purposive sampling. Interviews were thematically analysed using within and between group comparisons.Results: We conducted individual interviews and/or focus group discussions with 41 women: 30 (73%) women living with HIV and 11 (27%) women not living with HIV. Most women living with HIV who participated in in-depth interviews disclosed their status to their partners, and most partners agreed to get HIV tested only after disclosure. Nearly all women said their partners agreed to use condoms, but few used them consistently. Nearly all women believed their current and former partners had outside partners. Most women living with HIV who participated in in-depth interviews believed their current or other serious partners were the source of their infection. Some women thought their partner's infidelity was due to their partner's disinterest in sex with them during menstrual/ breakthrough bleeding. Some women included their partners in contraceptive decision-making when the partner was supportive.Discussion: Relationship dynamics affected decision-making for contraceptive and condom use, as well as serodisclosure for the women living with HIV in the study. All women reported challenges with consistent condom use with their male partners, although contraceptive use was generally more acceptable. Women included their partners in their decision-making concerning contraceptive use when they were supportive.

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.

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.

Influence of the preference for sons on contraceptive use in Bangladesh: A multivariate analysis

The preference for sons has been documented not only in Bangladesh but also in many Asian and African countries across various religions and social strata. This paper examines the levels, trends, and differentials in the use of contraceptives and investigates the effects of the preference for sons on contraception in Bangladesh. This research project extracted data from the last four nationally representative Bangladesh Demographic and Health Survey datasets (BDHS: 2004, 2007, 2011, and 2014) to examine the trends of preference for sons. The use of contraceptives among the respondents who had only daughters was comparatively lower than among those who had only sons due to a preference for sons. The analysis also reveals that the preference for sons was invariant with regards to various demographic and socioeconomic factors. Moreover, the analysis of religion in all four survey datasets indicates that Muslim women had stronger preferences for sons than their non-Muslim counterparts. Furthermore, the analysis showed that the preference for sons was strongest among women who had no education, did not work, and lived in rural areas.

Multilevel analysis of factors associated with unmet need for family planning among Malawian women

Background

Malawi has a high fertility rate which is also characterized by a relatively high prevalence of unmet need for contraception. However, little is known about the influence of individual- and community- level characteristics on unmet need in Malawi. This study examined the individual- and community- level factors associated with unmet need for family planning (FP) among Malawian women.

Methods

Data from the 2015–16 Malawi demographic and health survey were used to analyze 15, 931 women. The association between individual- and community- level factors and unmet need was assessed using multilevel binary logistic regression models.

Results

The prevalence of total unmet need was 21.0%. Women aged ≥35 years were more likely to have total unmet need [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.04–1.35] compared with those aged 15–24 years. Women who were married [aOR = 0.41, 95% CI = 0.35–0.48], and those employed [aOR = 0.78, 95% CI = 0.71–0.85] were associated with less likelihood of having total unmet need compared with unmarried, and unemployed women, respectively. At community-level, women from communities with a high percentage of women from rich households [aOR = 0.81, 95% CI = 0.67–0.96], and those from communities with a middle and high percentage of educated women [aOR = 0.86, 95% CI = 0.76–0.96 and aOR = 0.81, 95% CI = 0.70–0.93, respectively] were less likely to have total unmet need for FP compared with those from communities with low percentages of rich and educated women, respectively. The proportional change in variance showed that about 36.0% of total variations in the odds of unmet need across the communities were explained by both individual- and community-level factors. Moreover, the intraclass correlation showed that about 3.0% of the total variation remained unexplained even after controlling for both individual- and community-level factors.

Conclusion

Both individual- and community- level factors influenced unmet need for FP in Malawi. Public health practitioners should conduct community profiling and consider individual and community factors when designing FP programs.

Positive psychology as a strategy for promoting sustainable population policies

Demographic stability constitutes a paramount global environmental objective. Yet, decades of efforts, highlighting the perils of overpopulation, have failed to slow the rapid global population growth. In considering an alternative strategy, insights from the field of positive psychology are explored for their potential to inform future demographic policies. After briefly reviewing sustainable advocacy efforts, different theories behind individual fertility decisions are presented. Following, key components of prominent successful family planning interventions are analysed using a 'positive psychology' perspective. Three 'positive psychology' strategies are explored for their potential to inform sustainable population: a "direct" approach that emphasizes individual benefits rather than indirect gains through mitigation of damages; an emphasis on the convergence between the collective and individual benefits of two--child families; and application of behavioral change theories in demographic policies to better facilitate sustainable individual fertility decisions. The paper posits that a positive psychology conceptualization offers a promising way to re-think the design of demographic policies and frame sustainable population interventions.

Individual and community-level impact of infertility-related stigma in Malawi

Infertility, a common experience among women and men worldwide, remains on the margins of public health and medicine in low-resource settings. Previous studies identified associations between individual experiences of infertility and negative outcomes, particularly in contexts where childbearing is imperative, but few have examined broader implications of infertility and infertility-related stigma on communities. To understand the production and impact of infertility-related stigma, this study analyzes 12 focus group discussions (FGDs) conducted with 104 women and men in rural Malawi. FGDs, conducted July-September 2018, were used to elicit the range of community norms around family formation, pregnancy, fertility, and infertility. Data were analyzed through memo-ing during and after data collection and collaborative, thematic coding. We found that stigma manifested within existing systems of gender and power. Aligning with Link and Phelan's stigma framework (2001) there were three primary mechanisms by which infertility-related stigma was produced and reinforced: labeling of a person perceived to be infertile (i.e., establishing 'other'), perpetuating negative stereotypes associated with suspected causes of infertility (e.g., abortion, multiple sexual partners, weak sperm), and consequences of infertility that reinforced stigma (e.g., social ridicule and distancing, divorce). Labels, presumed causes, and consequences of infertility were entrenched within gender and sexuality norms. Women perceived as infertile were unable to follow a normative path to achieving adult status, presumed to be sexually transgressive, and considered "useless." Men's masculinity was questioned. Both women's and men's identities, as well as social positions within relationships and communities, were threatened by perceptions of infertility. Ultimately, the manifestation of infertility-related stigma contributed to an environment wherein the risk of being perceived as infertile was highly consequential and unrelenting. Pervasive stigma, at the community-level, impacts decisions around contraceptive use and timing of childbearing, as women and men not only wanted to avoid infertility, but also the appearance of infertility.

Lusting, learning and lasting in school: sexual debut, school performance and dropout among adolescents in primary schools in Karonga district, northern Malawi

Age at sexual debut is known to have implications for future sexual behaviours and health outcomes, including HIV infection, early pregnancy and maternal mortality, but may also influence educational outcomes. Longitudinal data on schooling and sexual behaviour from a demographic surveillance site in Karonga district, northern Malawi, were analysed for 3153 respondents between the ages of 12 and 25 years to examine the association between sexual debut and primary school dropout, and the role of prior school performance. Time to dropout was modelled using the Fine and Gray survival model to account for the competing event of primary school completion. To deal with the time-varying nature of age at sexual debut and school performance, models were fitted using landmark analyses. Sexual debut was found to be associated with a five-fold increase in rate of subsequent dropout for girls and a two-fold increase in dropout rate for boys (adjusted hazard ratio [aHR] of 5.27, CI 4.22-6.57, and 2.19, CI 1.77-2.7, respectively). For girls who were sexually active by age 16, only 16% ultimately completed primary schooling, compared with 70% aged 18 or older at sexual debut. Prior to sexual debut, girls had primary completion levels similar to those of boys. The association between sexual debut and school dropout could not be explained by prior poor school performance: the effect of sexual debut on dropout was as strong among those who were not behind in school as among those who were overage for their school grade. Girls who were sexually active were more likely to repeat a grade, with no effect being seen for boys. Pathways to dropout are complex and may differ for boys and girls. Interventions are needed to improve school progression so children complete primary school before sexual debut, and to improve sex education and contraception provision.

Understanding 'missed appointments' for pills and injectables: a mixed methods study in Senegal

INTRODUCTION

High discontinuation rates of contraceptive methods have been documented in sub-Saharan Africa. However, little is known about gaps within individual episodes of method use, despite their implications for unintended pregnancies. The objective of this mixed methods study was to examine the prevalence of, and explore the factors contributing to, delays in repeat appointments for pills and injectables in Senegal.

METHODS

First, we constructed a longitudinal data set of women's contraceptive consultations using routine records from 67 facilities in Senegal. Consultations for pills and injectables were classified as on time, delayed or with unknown delay status based on time since previous appointment. We described the prevalence of delayed appointments and used backward stepwise regression to build a mixed-effects model to investigate risk factors for delay. Second, we conducted workshops with family planning (FP) providers, and indepth interviews and focus group discussions with women of reproductive age, to explore factors contributing to delays.

RESULTS

Almost one-third (30%) of appointments for pills and injectables were delayed, resulting in risk of pregnancy. Previous delay, pill use, lower educational level, higher parity, third and subsequent visits, and Islamic faith were independently predictive of delays (p<0.04 for all). Although women's 'forgetfulness' was initially mentioned as the main reason for delays by women and providers, examining the routines around appointment attendance revealed broader contextual barriers to timely refills-particularly widespread covert use, illiteracy, financial cost of FP services and limited availability of FP services.

CONCLUSION

Delays in obtaining repeat pills and injections are common among contraceptive users in Senegal, exposing women to unintended pregnancies. Strategies to reduce such delays should move beyond a narrow focus on individual women to consider contraceptive behaviour within the broader socioeconomic and health systems context. In particular, effective interventions addressing low acceptability of contraception and appointment reminder strategies in high illiteracy contexts are needed.

Unintended Childbearing and Child Growth in Northern Malawi

Objective The study aims to assess whether unintended children experience slower growth than intended children. Methods We analysed longitudinal data linked to the Karonga Health and Demographic Surveillance Site collected over three rounds between 2008 and 2011 on women’s fertility intentions and anthropometric data of children. Using the prospective information on fertility intention we assessed whether unintended children are more likely to be stunted than intended children. We applied Propensity Score Matching technique to control for endogenous factors affecting both the probability that a family has an unwanted birth and a child with poor health outcomes. Results We found that 24 % of children from unwanted pregnancies were stunted compared with 18 % of mistimed pregnancies and 17 % of those from wanted pregnancies. However, these differences in probability of children being stunted, though in the expected direction, were not significant either for large or small families, after controlling for age. The number of children in the household was associated with stunting and boys were substantially more likely to be stunted than girls. Conclusion We found no significance difference in probability of being stunted by mother’s fertility intention.

Incidence of induced abortion in Malawi, 2015

Background

In Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15–44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates.

Methods

We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology.

Results

We estimate that approximately 141,044 (95% CI: 121,161–160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15–49 (95% CI: 32 to 43); which varied by geographical zone (range: 28–61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures.

Conclusions

The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34–35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

"New Users" Are Confusing Our Counting: Reaching Consensus on How to Measure "Additional Users" of Family Planning

FP2020's overarching goal is framed around the new metric of “additional users.” This measure inherently captures population-level change but has been conflated with other ambiguous metrics, such as “new users.” Therefore, we propose a standard set of terms to provide more consistent measurement. Although commonly used service-level metrics cannot be directly compared to the population-level metric of additional users, we describe 2 modeling approaches that can allow service-level data to inform estimates of additional users.

Postpartum uptake of contraception in rural northern Malawi: A prospective study

OBJECTIVES

Cross-sectional estimates of contraceptive use do not provide understanding of time to postpartum uptake. This paper uses a range of Malawian data sources: a prospective study to explore time to uptake of contraception and a cross-sectional survey to assess whether sexually active postpartum women whose fecundity has returned use contraception, and whether abstaining/amenorrheic women report using contraception.

STUDY DESIGN

A demographic surveillance site (DSS) in Malawi was used to identify 7393 women aged 15-49 years eligible for a 1-year prospective study of contraception using provider-recorded data on patient-held records (2012-2013). This provided a reliable record of time to uptake of postpartum contraception. The average timing of resumption of sexual activities after postpartum abstinence and return of menses was estimated from a population-based sexual behaviour survey in the DSS (2010-2011).

RESULTS

Of 4678 women recruited to the prospective contraception study, 442 delivered an infant during the observation period. Of these, 28.4% used modern contraception within 6 months of delivery. However, at 6-9 months after delivery, only 28.0% women had started menstruation and resumed sexual activities; of these, 77.6% used contraception. Amongst abstaining/amenorrheic women, a quarter reported contraceptive use.

CONCLUSIONS

The low uptake of postpartum contraception is likely due to many women abstaining and/or experiencing amenorrhea. Self-reports of contraceptive use amongst abstaining/amenorrheic women bring into question the quality of cross-sectional surveys and demonstrate that contraceptive use by women at low risk of pregnancy could contribute to the Malawi paradox of high contraceptive use and high fertility. Given relatively low risk of pregnancy in the postpartum period in this context, a focus on long-acting/permanent methods may be more effective to avert unintended pregnancies.

IMPLICATIONS

There has been increasing interest in the utility of postpartum contraceptive programmes to assist women to space births. Our findings suggest that, although uptake of contraception is low, this is partly due to postpartum abstinence and amenorrhea. Provision of long-acting/permanent methods will be more effective for women after delivery.