Getting to FP2020: Harnessing the private sector to increase modern contraceptive access and choice in Ethiopia, Nigeria, and DRC

A Longitudinal Multilevel Analysis of the Effects of Contraceptive Failures on Unintended Pregnancies among Women in Urban Nigeria

Unintended pregnancy is a global public health concern. However, the effect of contraceptive failure on unintended pregnancy remains unclear in Nigeria. We undertook a longitudinal analysis to examine the effect of contraceptive failure on unintended pregnancy among urban women in Nigeria. We used panel data from the Nigerian Urban Reproductive Health Initiative. The Measurement, Learning and Evaluation program conducted the surveys among a cohort of women aged 15-49 who were first interviewed at baseline in 2010/2011 and followed up at endline in 2014/2015. Analytic sample was 4140 women aged 15-49 who ever used contraceptives. We fitted three-level multilevel binary logistic regression models estimated with GLLAMM. The study established evidence that there is a significant effect of contraceptive failure on unintended pregnancy among urban women in Nigeria. The positive effect of between-person contraceptive failure indicates that respondents who experienced more contraceptive failure than the average in the sample had 5.26 times higher odds of unintended pregnancy (OR = 5.26; p-value < 0.001). Results also established a significant effect of within-person contraceptive failures among the respondents. Findings suggest there is evidence of a significant longitudinal effect of contraceptive failure on unintended pregnancy in urban Nigeria. Efforts to reduce unintended pregnancy must include interventions to address the problem of contraceptive failure among urban women in Nigeria.

Nigerian Women's Modern Contraceptive Use: Evidence from NDHS 2018

Nigeria has the largest population in Africa, a high fertility rate, and unmet needs for family planning. Family planning is a key strategy for sustainable development. Good knowledge of factors that determine contraceptive uptake is imperative for policy formulation. A nationally representative secondary dataset of 33,924 women aged 15-49 years who participated in the 2018 Nigeria Demographic and Health Survey was analyzed. Multivariate logistic regression was used to examine the association between various factors and the current use of modern contraceptives. The respondents' average age was 35.9 +/- 7.9 years. Overall, contraceptive prevalence was 16.6% for traditional methods and 12.2% for modern methods. Factors associated with an increase in modern contraception use were age 40-44 (aOR = 1.07, 95% CI: 0.75-1.53); being a working-class woman (aOR = 1.15, 95% CI: 0.99-1.33); living in an urban area (aOR = 1.14, 95% CI: 0.97-1.33); living in the South-West (aOR = 1.36, 95% CI: 1.03-1.79); increasing wealth (aOR = 0.78, 95% CI: 0.66-0.93);and health insurance (aOR = 1.22, 95% CI: 0.89-1. 68. Couple dynamics influencing modern contraceptive use were joint decision (aOR = 2.16, 95% CI: 1.81-2.59), self-decision on healthcare (aOR = 1.34, 95% CI: 1.06-1.70), and earning more than a partner (aOR = 1.14, 95% CI: 0.78-1.66). There are significant variations in contraceptive uptake attributable to socio-economic and political inequalities, requiring a holistic approach to mitigate barriers and improve contraceptive uptake.

Do private health providers help achieve Universal Health Coverage? A scoping review of the evidence from low-income countries

Universal Health Coverage (UHC) is the dominant paradigm in health systems research, positing that everyone should have access to a range of affordable health services. Although private providers are an integral part of world health systems, their contribution to achieving UHC is unclear, particularly in low-income countries (LICs). We scoped the literature to map out the evidence on private providers' contribution to UHC progress in LICs. Literature searches of PubMed, Scopus and Web of Science were conducted in 2022. A total of 1049 documents published between 2002 and 2022 were screened for eligibility using predefined inclusion criteria, focusing on formal as well as informal private health sectors in 27 LICs. Primary qualitative, quantitative and mixed-methods evidence was included, as well as original analysis of secondary data. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of the studies. Relevant evidence was extracted and analysed using an adapted UHC framework. We identified 34 papers documenting how most basic health care services are already provided through the private sector in countries such as Uganda, Afghanistan and Somalia. A substantial proportion of primary care, mother, child and malaria services are available through non-public providers across all 27 LICs. Evidence exists that while formal private providers mostly operate in well-served urban settings, informal and not-for-profit ones cater for underserved rural and urban areas. Nonetheless, there is evidence that the quality of the services by informal providers is suboptimal. A few studies suggested that the private sector fails to advance financial protection against ill-health, as costs are higher than in public facilities and services are paid out of pocket. We conclude that despite their shortcomings, working with informal private providers to increase quality and financing of their services may be key to realizing UHC in LICs.

Contextual factors influencing the roles of patent medicine vendors in the provision of injectable contraception services in Nigeria

BACKGROUND

Patent medicine vendors (PMVs) play vital roles in the delivery of family planning services in Nigeria and other developing countries. There is a growing recognition of the need to integrate them into the formal health care system as a strategy to increase the contraceptive prevalence rate and achieve universal health coverage. Though promising, the success of this proposition is largely dependent on a critical analysis of the factors which influence their operations. This study was designed to identify the contextual factors influencing the provision of injectable contraceptive services by PMVs and the broader effects of their activities on the health system to inform similar interventions in Nigeria.

METHODS

This was a qualitative study guided by the UK Medical Research Council's Framework for Complex Interventions. Twenty-seven in-depth interviews were conducted among officials of the association of PMVs, health workers, government regulatory officers and programme implementers who participated in a phased 3-year (2015-2018) intervention designed to enhance the capacity of PMVs to deliver injectable contraceptive services. The data were transcribed and analyzed thematically using NVIVO software.

RESULTS

The contextual factors which had implications on the roles of PMVs were socio-cultural and religious, the failing Nigerian health system coupled with government regulatory policies. Other factors were interprofessional tensions and rivalry between the PMVs and some categories of health care workers and increasing donors' interest in exploring the potentials of PMVs for expanded healthcare service provision. According to the respondents, the PMVs bridged the Nigerian health system service delivery gaps serving as the first point of contact for injectable contraceptive services and this increased contraceptive uptake in the study sites. A negative effect of their operation is the tendency to exceed their service provision limits, which has spurred a planned tiered PMV accreditation system.

CONCLUSIONS

This study has highlighted the contextual factors which define the roles and scope of practice of PMVs involved in injectable contraceptive service provision. Strategies and interventions aimed at expanding the healthcare delivery roles of PMVs must be encompassing to address the broader contextual factors which underpin their capacities and functions.

Associations of Urban Residence and Wealth Index With Various Sources of Contraceptives Among Young Women Aged 15-24 Years in 25 Sub-Saharan African Countries

PURPOSE

Appreciating user differences in contraceptive sources is essential for improving contraceptive access and safeguarding an equitable and sustainable future. Therefore, this study explored whether urban residence and individual wealth are associated with where women access contraception (e.g., government, private, or nongovernmental organization provider) and assessed whether these associations are modified by the income level in the respondents' country of residence.

METHODS

We analyzed the cross-sectional data of Demographic Health Surveys conducted between 2009 and 2020 in 25 countries. The final data set included 25,081 young women aged between 15 and 24 years who are using contraceptives. Multinomial logistic regression models were established to assess the associations of our outcome variable, namely, various contraceptive sources, with our main independent variables, namely, urban residence and wealth index. We also assessed the potential effect modification by country income level on the above associations.

RESULTS

We observed obvious urban-rural and rich-poor disparities in odds of using contraceptive sources. Generally, living in urban residences and being wealthy were positively associated with all sources of contraceptives. However, these associations were mostly modified by country income level. People living in urban residences utilized more private sources, especially in low-income (beta coefficient, B = 0.973) and upper-middle-income countries (B = 1.361). Young women in urban areas across all analyzed countries were also more likely to use contraceptives from other sources (B = 0.267). In addition, women from poor households were less likely to use private sources (B = -1.166) and other sources (B = -0.547).

DISCUSSION

Even though young women may prefer private sources of contraceptives due to their confidentiality and flexible hours, these sources carry more benefits for rich and urban young women than for poor and rural women. The differential accessibility and affordability may account for the observed urban-rural and rich-poor disparities in using contraceptive sources, respectively, and the income level of a country is likely to modify such disparities.

What is needed to improve quality of implant removal services in Nigeria? results of a landscape assessment

Introduction

Stunning recent increases in subdermal contraceptive implant use, especially in sub-Saharan Africa, necessitate availability of quality implant removal services. In Nigeria, service delivery capacity and coverage for removal are lacking, despite strong government commitment and rapid uptake; there is a dearth of knowledge about barriers to quality implant removals in Nigeria.

Methods

To determine access to and quality of contraceptive implant removal services, a landscape assessment was conducted in two states in Nigeria, focusing on four conditions for quality delineated in the Global Implant Removals Task Force framework. This mixed-methods approach integrated results from a desk review, a survey of health facilities and family planning managers, review of implant service statistics, and key informant interviews with providers and diverse stakeholders.

Results

Seventy percent of providers (N = 21 of 30) had experienced problems performing implant removal, usually due to deeply inserted implants and equipment shortages. Providers had low confidence in performing removal and poor knowledge of implant removal steps. No facilities assessed had comprehensive equipment required for implant removal. Few facilities maintained systems or referral pathways to support difficult removals; difficult removals are absent from training manuals, and no formal trainings have been conducted. While most facilities collect data on removals, family planning dashboards do not capture it; few facilities use data for quality improvement.

Conclusion

This study identified numerous challenges to quality implant removal, including poorly trained providers, inadequate supplies, underutilization of data on removals, and inability to manage difficult removals. As demand for implant removals skyrockets, providers need improved training in implant removal, appropriate job aids, supportive supervision, and effective procurement systems to ensure availability of supplies and equipment for removal. Tracking removals and reasons for removal in information systems and the Family Planning dashboard could sensitize providers to need for implant removals and improve data for decision-making in facilities and health systems.

Changes in clients' perceptions of family planning quality of care in Kaduna and Lagos States, Nigeria: A mixed methods study

Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) are crucial to improving access to family planning (FP) services in Nigeria. Although the private sector is preferred for convenience, availability of commodity, privacy, and timeliness, less well known is the quality of care received by clients who obtain FP services from CPs and PPMVs. This paper seeks to explore the use of validated quality of care measures for programming in Kaduna and Lagos States and to assess how these measures worked in capturing changes in quality of care using client exit interviews implemented at two time points. Using validated measures of quality of care, 598 and 236 exit interviews in rounds 1 and 2 were conducted with FP clients aged 18–49 years old. The quality of care domains were assessed using 22 questions. A weighted additive quality score was created, and scores were grouped into three: low, medium, and high quality. Changes in quality of care received were examined using χ2 test. A subset of 53 clients were selected for in-depth interviews. Deductive and inductive approaches were used for coding, and data analysis was thematic. In Lagos, we observed increases in 16 out of 22 items while in Kaduna increases were only observed in 8 items. For instance, increases were observed in the proportion of women who experienced visual privacy between rounds 1 and 2 in Lagos (74%–89%) and Kaduna (66%–82%). The quality of care received by clients changed over time. Women who reported high quality care in Lagos increased from 42% to 63%, whereas women who reported high quality care in Kaduna decreased from 35% to 21%. In both states, in-depth interviews revealed that women felt they were treated respectfully, that their sessions with providers were visually private, that they could ask questions, and that they were asked about their preferred method. This study demonstrates that clients received high quality of care services from providers (CPs and PPMVs) especially in Lagos, and such services can be improved over time. Continuous support may be required to maintain and prevent reduction in quality of FP counseling and services, particularly in Kaduna.

Two decades of family planning in Ethiopia and the way forward to sustain hard-fought gains!

Family planning (FP) is a human right, and ensuring women’s access to FP is central to protecting the health and wellbeing of mothers and children. Over the past two decades, Ethiopia has made FP service more widely available, increasing the contraceptive prevalence rate from 8% in 2000 to 41% in 2019. This remarkable fivefold increase can be attributed to the country’s overall development, including investment in education (particularly for girls) and reduction in child marriage, as well as the adoption and implementation of several enabling FP policies and strategies. In Ethiopia, achieving universal access to sexual and reproductive health care services, information, and education, including FP, by 2030 means enhancing these effective government policies and programs. Achieving universal access requires increasing financial resources, including domestic financing through greater government commitment for commodity security and program implementation; strengthening public–private partnerships; and improving service delivery for populations that are hard to reach and/or in humanitarian crisis. The persistence of equity gaps due to regional and/or sociodemographic disparities and the low quality of FP service delivery challenge our progress in Ethiopia. The papers included in this supplement provide additional detail on the overall progress described in this commentary and highlight focal areas for improvement in responding to unmet needs. Current policies and services must adapt, maintain, and build upon these gains and focus on targeted actions in areas identified for improvement. We must sustain the hard-fought gains of the past decades and help shape the prosperous future we advocate for in our society by 2030 and beyond—Leaving No One Behind.

Continuation and user satisfaction of the levonorgestrel intrauterine system (LNG IUS) contraceptive in Nigeria

Background: The hormonal intrauterine device or intrauterine system (IUS) also known as the levonorgestrel intrauterine system (LNG-IUS) is a highly effective hormonal intra-uterine contraceptive. However, services offering the method are not widely available in Nigeria and little evidence exists on the dynamics of its use. We examined the continuation rate and satisfaction with the IUS among the user population. Methods: This prospective longitudinal phone survey involved a baseline survey of users at two-weeks post-insertion of the LNG IUS, recruited from 40 clinics across 17 states in Nigeria, with a follow-up survey at the 3rd and 12th months. A total of 208 users were interviewed at baseline, 98 at three months, and 73 at 12 months. User family planning and the IUS use experiences were elicited, as well as the continuation rate and satisfaction with the method at three and 12 months. Results: At three- and 12 months post-insertion, 96.9% (95% CI: 91.3, 99.3) and 91.8% (95% CI: 82.9, 96.9), respectively, reported still using the LNG IUS, with none out of the few users who discontinued the method reporting a method failure. Discontinuation was mainly a result of the experience of menstrual bleeding or amenorrhea (25.0%), experiences of pain with the method (18.8%), and partner complaining about strings (16.7%). High satisfaction with the LNG IUS (76.5% at three months and 86.3% at 12 months post-insertion) was reported. Satisfaction with LNG IUS was significantly associated with not having breast tenderness/pain (88.2%) and no vaginal bacterial infection (87.5%) at 12 months compared to experiencing breast tender/pain (50.0%) and vaginal infection (0.0%) (p<0.05). Conclusion: High user continuation and satisfaction with IUS indicates the positive potential of the method as a contraceptive in Nigeria.

The public-sector family planning program impact scores in association with long acting reversible contraceptive use among young women in 22 Sub-Saharan African countries; A pooled multi-level analysis

OBJECTIVE

The objective of this study was to evaluate the role of public-sector family planning program impact scores and other country-level factors on LARC use among young women aged 15-24.

STUDY DESIGN

We conducted this research using a large population database covering several decades' worth of multi-wave cross-sectional samples of the demographic health survey (DHS) and the World Bank website data. We carried out a multi-level analysis on data from 1990 to 2019 from 22 Sub-Saharan African countries, with 163,242 participants.

RESULTS

We found LARC use was at 3.1% of all young women under study. Sierra Leone, 2019 survey had the highest LARC use at 21,961 per 100,000. A 10% increase in public-sector family planning program impact scores was positively associated with LARC use with odds ratio of 1.44, 95% CI, 1.43- 1.45). We also noted that a 1% increase in HIV prevalence was associated with a reduced odds ratio of LARC use at 0.75 (95% CI, 0.70-0.81).

CONCLUSIONS

Findings from this study provide empirical evidence highlighting the importance of country-level factors in influencing LARC use among young women in sub-Saharan Africa IMPLICATIONS: For young women in Africa, policymakers need to increase their effort on national family planning programs especially in the public sector. Broader societal level interventions to improve LARC use are required. Specific interventions must address the complexities of HIV prevention and LARC use to benefit young women living in countries with a high HIV prevalence.

Process evaluation of an intervention to improve access to injectable contraceptive services through patent medicine vendors in Nigeria: a mixed methods study

BACKGROUND

The low utilisation of modern contraceptives in many low- and middle-income countries remains a challenge. Patent medicine vendors (PMVs) that operate in the informal health sector, have the potential to address this challenge. Between 2015 and 2018, the Population Council, in collaboration with the Federal and State Ministries of Health and the Pharmacy Council of Nigeria, trained PMVs in six states to deliver injectable contraceptive services. Outcome evaluation demonstrated increased client uptake of injectable contraceptive services; however, there is limited information on how and why the intervention influenced outcomes. This study was conducted to elucidate the processes and mechanism through which the previous intervention influenced women's utilisation of injectable contraceptive services.

METHODS

The study utilised a mixed methods, convergent parallel design guided by the UK Medical Research Council framework. Quantitative data were obtained from 140 trained PMVs and 145 of their clients in three states and 27 in-depth interviews were conducted among relevant stakeholders. The quantitative data were analysed descriptively, while the qualitative data were analysed thematically.

RESULTS

The results revealed that even after the completion of the PMV study which had a time-bound government waiver for injectable contraceptive service provision by PMVs, they continued to stock and provide injectables in response to the needs of their clients contrary to the current legislation which prohibits this. The causal mechanism that influenced women's utilisation of injectable contraceptives were the initial training that the PMV received; the favourable regulatory environment as demonstrated in the approval provided by government for PMVs to provide injectable contraceptives for the duration of the study; and the satisfaction and the confidence the female clients had developed in the ability of the PMVs to serve them. However, there were gaps with regards to the consistent supply of quality injectable contraceptive commodities and in PMVs use of job aids. Referral and linkages to government or private-owned facilities were also sub-optimal.

CONCLUSION

PMVs continue to play important roles in family planning service provision; this underscores the need to formalize and scale-up this intervention to aid their integral roles coupled with multi-faceted initiatives to enhance the quality of their services.

Unequal access and use of contraceptives among parenting adolescent girls in sub-Saharan Africa: a cross-sectional analysis of demographic and health surveys

OBJECTIVE

We examined the divergent patterns, prevalence and correlates of contraceptive use among parenting adolescents in sub-Saharan Africa using the Demographic and Health Survey datasets of 17 countries.

DESIGN

We included a weighted sample of 9488 parenting adolescent girls in our analysis. Current contraceptive use was defined as the use of any methods to delay or avoid getting pregnant at the survey time. We reported the prevalence of any contraceptive use for all countries and used multilevel binary logistic regression analysis to examine the individual and contextual factors associated with contraceptive use.

OUTCOME MEASURES

Contraceptive use.

RESULTS

We found an overall contraceptive prevalence of 27.12% (CI 27.23% to 28.03%) among parenting adolescent girls in sub-Saharan Africa, ranging from 70.0% (CI 61.76% to 77.16%) in South Africa to only 5.10% (CI 3.04% to 8.45%) in Chad. The prevalence of contraceptive use was lowest in West andCentral Africa, with most countries having less than 20% prevalence. Increasing age (adjusted OR (aOR)=1.46, 95% CI 1.28 to 1.65), being married (aOR=1.63, 95% CI 1.43 to 1.87), having a secondary or higher level of education (aOR=2.72, 95% CI 2.25 to 2.3.27), and media exposure (aOR=1.21, 95% CI 1.08 to 1.36), were associated with higher odds of contraceptive use in the pooled data but preference for a higher number of children (more than five children) (aOR=0.61, 95% CI 0.52 to 0.72) was related to lower likelihood of use. Significant heterogeneity was observed in the country-level disaggregated results.

CONCLUSION

African countries differ widely when it comes to contraceptive use among parenting adolescent girls, with only three countries having a relatively high prevalence of use. The governments of countries in sub-Saharan Africa, particularly those in West and Central Africa, should invest in expanding access to contraceptives for adolescent mothers to prevent repeat pregnancy and improve the overall well-being of parenting adolescent girls.

Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption

Approximately 214 million women of reproductive age lack adequate access to contraception for their family planning needs, yet patterns of contraceptive availability have seldom been examined. With growing demand for contraceptives in some areas, low contraceptive method availability and stockouts are thought to be major drivers of unmet need among women of reproductive age, though evidence for this is limited. In this research, we examined trends in stockouts, method availability and consumption of specific contraceptive methods in urban areas of four sub-Saharan African countries (Burkina Faso, Democratic Republic of Congo, Kenya and Nigeria) and India. We used representative survey data from the Performance Monitoring for Action Agile Project that were collected in quarterly intervals at service delivery points (SDP) stratified by sector (public vs private), with all countries having five to six quarters of surveys between 2017 and 2019. Among SDPs that offer family planning, we calculated the percentage offering at least one type of modern contraceptive method (MCM) for each country and quarter, and by sector. We examined trends in the percentage of SDPs with stockouts and which currently offer condoms, emergency contraception, oral pills, injectables, intrauterine devices and implants. We also examined trends of client visits for specific methods and the resulting estimated protection from pregnancy by quarter and country. Across all countries, the vast majority of SDPs had at least one type of MCM in-stock during the study period. We find that the frequency of stockouts varies by method and sector and is much more dynamic than previously thought. While the availability and distribution of long-acting reversible contraceptives (LARCs) were limited compared to other methods across countries, LARCs nonetheless consistently accounted for a larger portion of couple years of protection. We discuss findings that show the importance of engaging the private sector towards achieving global and national family planning goals.

Individual and community factors associated with unintended pregnancies among women of advanced reproductive age in Nigeria

Studies have examined individual and community level factors associated with unintended pregnancies. However, existing studies tends to focus the general population of reproductive age women without isolating women of advanced reproductive age (women at the age range of 35-49 years) for specific research attention. There is need for specific attention on this group of women because pregnancies among them whether intended or unintended elevate obstetric risks for both mother and child. This study examines associated individual and community factors of unintended pregnancies among women of advanced reproductive age in Nigeria. Data were extracted from the 2018 Nigeria Demographic and Health Survey. A weighted sample of 12,509 women was analyzed. Three multilevel logistic regression models were estimated. The study revealed a 10.3% prevalence of unintended pregnancies. Individual characteristics such as maternal age, number of living children, delayed marriage, and community characteristics such as high community poverty and high community unmet contraceptive need were significantly associated with unintended pregnancies. Variations in unintended pregnancies across the communities were more attributable to individual factors. Interventions should develop specific strategies tailored toward women of advanced reproductive age.

A comparative analysis of the availability of family planning services in the social franchise and non-franchise private health facilities in Kajiado County, Kenya

Introduction

this study assessed the availability of family planning (FP) services in the social franchise and non-franchise private health facilities in Kajiado County, Kenya. Social franchises refer to a standardized delivery model of engaging private health facilities under a common brand name or contractual arrangement.

Methods

this was a facility-based mixed-method approach. Quantitative data was collected through 581 FP client exit interviews and a facility inventory in 32 health facilities. Association between the clients' characteristics and use of FP services was tested using univariable and multivariable logistic regression. Qualitative data were collected through five focus group discussions with FP clients and 16 key informant interviews with service providers and analysed through thematic analysis.

Results

the findings show that FP methods availability was the same across all facilities (p = 0.206). The findings were supported by views from the clients who indicated that contraceptives were available. Statistically significant predictors of FP use were found to be women's age group 20-24 years (Adjusted Odds Ratio (AOR) = 2.30, 95% Confidence Interval (CI): 1.12, 4.69) or 25 to 34 years (AOR = 2.10, 95% CI: 1.86, 2.36) versus the 15-19 years and the clients with tertiary level education and above compared primary level education and below (AOR = 0.020, 95% CI: 1.13, 4.41).

Conclusion

this study demonstrates the need to support all private health facilities with policies and supplies to expand access to all FP services, especially for adolescents.

Utilization of Private Sector Family Planning Services in Malaysia

BACKGROUND

The private sector is playing an increasingly important role in family planning services globally. The active participation of private providers is associated with a higher contraceptive prevalence rate.

OBJECTIVES

To examine the differentials and determinants of the utilization of private providers for family planning services.

METHOD

This study used the 2014 Malaysian Population and Family Survey data. Cross-tabulations and logistic regression were performed on 1,817 current users of modern methods.

RESULTS

Overall, 26% of modern method users obtained their supplies from private clinics/pharmacies and 15.2% from other sources, such as drug stores and sundry shops. The odds of utilizing the private sector for family planning services differ significantly across regions and socio-economic groups. The odds of obtaining supply from the private clinics/pharmacies were higher among the Chinese and urban women (AOR > 1), and it was lower among those from the eastern region (AOR = 0.47, 95% CI = 0.30-0.73). Non-Bumiputera, urban, higher educated, and working women, and those whose husbands decided on family planning had higher odds of obtaining the supply from the other sources (AOR > 1).

CONCLUSION

The private sector complements and supplements the public sector in providing family planning services to the public.

Mixed-methods study on pharmacies as contraception providers to Kenyan young people: who uses them and why?

OBJECTIVES

This study sought to answer two questions: (1) what are the characteristics of young Kenyans aged 18-24 who use contraception obtained at pharmacies, and (2) why are pharmacies appealing sources of contraception?

DESIGN AND SETTING

This was a mixed-methods study in one peri-urban part of Kwale County, Kenya. Methods included cross-sectional survey (n=740), six focus group discussions, 18 in-depth interviews and 25 key-informant interviews. Quantitative data analysis identified factors pushing young people to pharmacies for modern contraception versus other sources. Qualitative data analysis identified reasons pharmacies were perceived to be appealing to young clients.

PARTICIPANTS

Participants were (1) young people aged 18-24 from the study area, including a subset who had recently purchased contraception from a pharmacy; or (2) pharmacy personnel and pharmacy stakeholders.

RESULTS

Among surveyed participants who had ever had sexual intercourse and had used modern contraception at last sexual intercourse, 59% obtained it from a pharmacy. In multivariable analysis, participants who used a condom or emergency contraception as well as those living alone were significantly more likely to get contraception from pharmacies. Pharmacies were valued for their convenience, privacy, non-judgmental and personable staff, service speed, as well as predictable and affordable prices.

CONCLUSIONS

Our findings indicate a high percentage of young people in Coastal Kenya use pharmacies for contraception. Our inclusion of emergency contraception users partially explains this. Pharmacies were perceived to be everything that health facilities are not: fast, private and non-limiting. Policy-makers should recognise the role of pharmacies as contraception providers and look for opportunities to link pharmacies to the public health system. This would create a network of accessible and appealing contraception services for young people.

Scaling Up Access to Implants: A Summative Evaluation of the Implants Access Program

The Implants Access Program increased access to implants by addressing price, supply chain, service delivery, and knowledge and awareness barriers. Sustaining progress requires institutionalized mechanisms to continue global efforts and long-term assurances that implants’ low price will be maintained.

The Implants Access Program (IAP) was a partnership between public and private organizations that aimed to increase access to contraceptive implants for women in low-income countries. The partnership began with 2 volume guarantee agreements that reduced the price of implants by approximately 50% and was complemented by efforts to address supply chain, service delivery, and knowledge and awareness barriers. We conducted a summative evaluation to identify key insights related to the IAP’s relevance, effectiveness, and sustainability. We completed a desk review of program materials and published literature, followed by 42 in-depth interviews, including global stakeholders and country stakeholders in 3 case example countries: Kenya, Nigeria, and Uganda. The evaluation found evidence of increased access to implants including a 10-fold increase in procurement between 2010 and 2018 and an increase in prevalence of contraceptive implants during this same period. The IAP leveraged global family planning efforts taking place at the time, and its partnerships offered a business case for manufacturers to support increased access to implants. Enhanced supply chain visibility and coordination helped limit country-level stock-outs, and the IAP built on existing in-country delivery capacity. Although the IAP was able to address key challenges due to its effective collaboration and coordination at global and country levels, sustaining progress requires institutionalized mechanisms to continue global efforts and long-term assurances that the low price of implants will be maintained. Over 6 years, the IAP supported tremendous progress in increasing access to implants for women in low-income countries by building a public- and private-sector collaboration that focused on systems change in the family planning field. This partnership matched a unique response to a unique problem: building tools, systems, and capacity that can inform and support the introduction and scale-up of new and underutilized contraceptive methods.

Pharmacists as youth-friendly service providers: documenting condom and emergency contraception dispensing in Kenya

Objectives

This Kenya-based study ascertained whether pharmacies were an untapped source of ‘youth-friendly’ health services by determining (1) whether young people (aged 18–24) could successfully obtain condoms and emergency contraception (ECP); (2) whether contraceptives were dispensed according to national guidelines; and (3) how young people felt about obtaining ECP and condoms from pharmacy personnel.

Methods

This study used several methods to capture and cross-check purchasing experiences as reported by young people with those of dispensing pharmacy personnel. These included: focus group discussions; in-depth interviews; key informant interviews; and mystery shoppers.

Results

When in stock, young people were successfully able to obtain ECP and condoms from pharmacies. Counselling was sporadic: when it happened, it was not always accurate. Despite a lack of counselling, young people reported being satisfied with the quick, transactional interaction with pharmacy personnel.

Conclusions

The brief, transactional interactions between pharmacy personnel and young clients appear to be ‘youth-friendly enough’. While there is room to strengthen the services provided (improving both accuracy and scope), this should be done in a manner that does not fundamentally alter the current interaction.

Building a transformative agenda for accountability in SRHR: lessons learned from SRHR and accountability literatures

Global strategies and commitments for sexual and reproductive health and rights (SRHR) underscore the need to strengthen rights-based accountability processes. Yet there are gaps between these ambitious SRHR rights frameworks and the constrained socio-political lived realities within which these frameworks are implemented. This paper addresses these gaps by reviewing the evidence on the dynamics and concerns related to operationalising accountability in the context of SRHR. It is based on a secondary analysis of a systematic review that examined the published evidence on SRHR and accountability and also draws on the broader literature on accountability for health. Key themes include the political and ideological context, enhancing community voice and health system responsiveness, and recognising the complexity of health systems. While there is a range of accountability relationships that can be leveraged in the health system, the characteristics specific to SRHR need to be considered as they colour the capabilities and conditions in which accountability efforts occur.

Quality of Family Planning Counseling in Ethiopia: Trends and determinants of information received by female modern contraceptive users, evidence from national survey data, (2014- 2018)

BACKGROUND

Family planning counseling is critical for women to make informed reproductive and sexual health decisions. Despite Ethiopia's success in expanding access to family planning services, information on the quality of family planning counseling is limited. The objectives of this study were to assess whether the quality of counseling from the female client´s perspective has changed over time (2014 to 2018) and to investigate determinants associated with the quality of counseling to provide a more nuanced understanding of disparities in sexual and reproductive health outcomes in Ethiopia.

METHODS

Data were obtained from five rounds of the Ethiopian Performance Monitoring and Accountability 2020 female survey questionnaire. Quality of counseling was categorized into four levels based on the responses of the questions that compose the Method Information Index, a core Family Planning 2020 indicator that serves as a proxy for quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The proportion of female contraceptive users that received good counseling were examined over time by each region, demographic characteristics, and contraception method type and source. Ordinal logistic regression was applied to the last survey round (2018) to investigate determinants associated with counseling quality.

RESULTS

The proportion of female contraception users that reported receiving information on all three questions did not significantly change over the period 2014 to 2018. Overall quality of counseling on family planning was low, with only 30% of women reporting receiving sufficient information during counseling. The likelihood of good quality counseling was the least among those who had no formal schooling when compared to those who had higher educational attainment (OR = 0.70, 95% CI: 0.50, 0.97). Women from the wealthiest quintile were 1.72 times more likely (95% CI: 1.10, 2.69) to receive good quality counseling when compared to women in the lower wealth quintile. Women from rural areas were 1.51 times more likely to have received good counseling when compared to those in urban areas (95% CI: 1.04, 2.18). Amhara residents were less likely to receive good counseling when compared to the SNNPR (OR: 0.51, 95% CI: 0.32, 0.81). Women who acquired their method from the private sector had worse counseling (OR: 0.31, 95% CI: 0.23, 0.41) when compared to the public sector. Those using short-acting methods were more at risk of receiving lesser quality counseling when compared to users of long-acting methods (OR: 0.58, 95% CI: 0.46, 0.72).

CONCLUSION

The results of this analysis indicated that Ethiopia's overall progress in modern contraceptive use has not been accompanied by a corresponding increase in the quality of family planning counseling. Improving the quality of contraception counseling for women across all demographics, including wealth quintiles and education, is a crucial strategy to support positive reproductive health outcomes with a rights-based focus. Based on the findings of this study, it is essential to emphasize the need to do proper counseling for all methods including short-acting methods especially for those working the private sector and some of the regions which have lower prevalence of good counseling. Further community-based participatory and qualitative research should focus on understanding the root causes and barriers to the delivery of high-quality counseling in Ethiopia.

FPwatch: Facility-based Survey Data for Family Planning Market Analysis in Five FP2020-focus Countries

This article describes datasets for the FPwatch Project, a comprehensive facility‐based family planning survey conducted by Population Services International in five countries in Africa and Asia from 2015 to 2017. Contents cover research design and background, methodology, sample selection, data collection, an overview of FPwatch indicators, and quality assurance measures taken. These datasets from the Democratic Republic of Congo, Ethiopia, India, Myanmar, and Nigeria complement other facility‐based family planning surveys and are unique in their large‐scale, standardized methodology, and comprehensive sampling approach. In addition, all datasets but Myanmar (private only) include both private and public facilities, a feature that gives a more complete picture of the family planning supply environment. Because of these factors, the data is well suited to inform global family planning efforts.