Varying family planning strategies across age categories: differences in factors associated with current modern contraceptive use among youth and adult women in Luanda, Angola

Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review

Background

Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population.

Methods

We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review.

Results

Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services.

Conclusion

The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.

Socio-economic inequalities in non-use of modern contraceptives among young and non-young married women in India

BACKGROUND

It is documented that married women do not utilize contraceptive methods, because of the fear of adverse effects, no or seldom sexual interaction; perception that they should not use contraception during breastfeeding, postpartum amenorrhea, or dissatisfaction with a specific method of contraception. The current study aimed to examine the socio-economic inequalities associated with the non-use of modern contraceptive methods among young (15-24 years) and non-young (25-49 years) married women and the contributing factors in those inequalities.

METHODS

The present study utilized the cross-sectional data from the fourth round of the National Family Health Survey (NFHS-4) with a sample of 499,627 women who were currently married. The modern methods of family planning include sterilization, injectables, intrauterine devices (IUDs/PPIUDs), contraceptive pills, implants, the standard days method, condoms, diaphragm, foam/jelly, the lactational amenorrhea method, and emergency contraception. Multivariable logistic regression analysis was used to estimate the odds of non-use of modern contraceptive methods according to different age groups after controlling for various confounding factors. Additionally, concentration curve and Wagstaff decomposition method were used in the study.

RESULTS

The prevalence of non-use of modern contraceptive use was higher among women from young category (79.0%) than non-young category (45.8%). The difference in prevalence was significant (33.2%; p < 0.001). Women from non-young age group had 39% significantly lower odds of non-use of modern contraceptive use than women from young age group (15-24 years) [AOR: 0.23; CI: 0.23, 0.23]. The value of concentration quintile was -0.022 for young and -0.058 for non-young age groups which also confirms that the non-use of modern contraceptives was more concentrated among women from poor socio-economic group and the inequality is higher among non-young women compared to young women. About 87.8 and 55.5% of the socio-economic inequality was explained by wealth quintile for modern contraceptive use in young and non-young women. A higher percent contribution of educational status (56.8%) in socio-economic inequality in non-use of modern contraceptive use was observed in non-young women compared to only -6.4% in young women. Further, the exposure to mass media was a major contributor to socio-economic inequality in young (35.8%) and non-young (43.2%) women.

CONCLUSION

Adverse socioeconomic and cultural factors like low levels of education, no exposure to mass media, lack of or limited knowledge about family planning, poor household wealth status, religion, and ethnicity remain impediments to the use of modern contraceptives. Thus, the current findings provide evidence to promote and enhance the use of modern contraceptives by reducing socioeconomic inequality.

Unmet need for contraception among married adolescent girls and young women in Haramaya Health and demographic surveillance system, Eastern Ethiopia

Background

The prevalence of unmet need for contraception is the highest in low- and middle-income countries (LMIC). Contraceptive use among young married or unmarried women is lower than that among older women in developing countries. Previous studies generalized the findings to all women of reproductive age and have not investigated psychosocial factors that influence contraceptive use. This study aimed to identify factors associated with unmet need for contraception among young married women in the Haramaya Health and Demographic Surveillance System (HDSS), eastern Ethiopia.

Methodology

A cross-sectional, community-based study of young married women aged 15-24 years was conducted. A simple random sampling method was used to select 550 young married women. Data were collected using a pretested structured questionnaire. Using adjusted odds ratio (AOR) with a 95% confidence interval (CI), factors associated with unmet need for contraception were identified using multivariable logistic regression analysis.

Results

The overall prevalence of unmet need for contraception was 154 (30.3%). Adolescents (15-19) (AOR = 2.05, 95% CI: 1.16-3.62), husbands' negative attitude toward contraception (AOR = 2.1, 95% CI: 1.05-4.46), and no previous use of contraception (AOR = 3.9, 95% CI: 2.29-6.71) were significantly and positively associated with unmet need for contraception. On the contrary, young women with secondary education or higher (AOR = 0.55, 95% CI: 0.28-1.084) were negatively and significantly associated with unmet need for contraception.

Conclusion

The prevalence of unmet need for contraception among young women in Haramaya was high. Unmet need was affected by age, husbands' attitude toward contraceptives, the educational status of women, and previous use of contraception. This study underscored the need to improve girls' educational status to empower them in making contraceptive use decisions with their partners. Programs should also engage male partners who are perceived as key decision-makers when it comes to contraceptive use.

Prevalence and determinants of unintended pregnancy in Ethiopia: narrative synthesis and meta-analysis

BACKGROUND

Unintended pregnancy has enormous health, social and psychological impacts. Thus, comprehensive local evidence is required to guide interventions to prevent the occurrence and consequences of unintended pregnancy. This systematic review was conducted to examine the prevalence and determinants of unintended pregnancy in Ethiopia.

METHODS

The review was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Synthesis Without Meta-analysis (SWiM) guideline. Electronic databases including Medline/PubMed, Cochrane Library, CINAHL, Google scholar, and African journal online were searched to retrieve studies published from January 1/1990 to October 30/2020. Grey literatures were accessed from the online libraries of academic institutions in Ethiopia using the Google search engine. The qualities of the studies were assessed using Joanna Briggs Institute critical appraisal checklists. The retrieved studies were analyzed using STATA software version 13. The prevalence of unintended pregnancy was pooled using the random-effects model. The evidences on the determinants of unintended pregnancy were summarized in a narrative format. The statistical heterogeneity between studies was quantified by using the I-square values. Sub-group analysis and meta-regressions were done to identify the sources of heterogeneity among studies.

RESULTS

A total of 250 studies were retrieved of which 25 studies with 23,030 women were included for meta-analysis. Only 24 studies scrutinized the determinants of unintended pregnancy. The overall prevalence of unintended pregnancy was 30 % (95% CI; 27-33 %) with high heterogeneity among studies (I2 = 95.06 %). The pooled prevalence of unwanted and mistimed pregnancy was 12 &17% respectively. The study region was the source of heterogeneity whereas study setting, study year, sample size, and study quality score were not the sources of heterogeneity (p > 0.1). Unintended pregnancy was positively associated with a low level of education, poverty, multiparity, rural residence, extreme ages, being unmarried, lack of decision-making power, inaccessibility of health facilities, poor knowledge, and non-use of contraceptives.

CONCLUSIONS

The pooled prevalence of unintended pregnancy in Ethiopia was high. Empowering women and ensuring the accessibility of quality family planning services can reduce the prevailing high prevalence of unintended pregnancy. Interventions that target rural, poor, unmarried, multiparous, less-educated, and adolescent women are also important to avert untended pregnancy in Ethiopia.

Modern contraceptive utilization and its associated factors among married women in Senegal: a multilevel analysis

Background

Utilization of modern contraceptives is still low in low-and middle-income countries, although fertility and population growth rates are high. In Senegal, modern contraceptive utilization is low, with few studies focusing on its associated factors. This study examined modern contraceptive use and its associated factors among married women in Senegal.

Methods

Data from the 2017 Continuous Demographic and Health Survey (C-DHS) on 11,394 married women was analysed. We examined the associations between the demographic and socioeconomic characteristics of women and their partners and modern contraceptive use using multilevel logistic regression models. Adjusted odds ratios with 95% confidence intervals (CI) were estimated.

Results

The utilization of modern contraceptives among married women was 26.3%. Individual level factors associated with modern contraceptive use were women’s age (45–49 years-aOR = 0.44, 0.30–0.63), women’s educational level (higher-aOR = 1.88, 1.28–2.76) husband’s educational level (higher-aOR = 1.43, 1.10–1.85)), number of living children (5 or more children-aOR = 33.14, 19.20–57.22), ideal number of children (2 children-aOR = 1.95, 1.13–3.35), desire to have more children (wants no more-aOR = 2.46, 2.06–2.94), ethnicity (Diola-aOR = 0.70, 0.50–0.99), media exposure (yes-aOR = 1.44, 1.16–1.79)), wealth index (richer-aOR = 1.31, 1.03–1.67) and decision making power of women (decision making two-aOR = 1.20, 1.02–1.41). Whereas, region (Matam-aOR = 0.35, 0.23–0.53), place of residence (rural-aOR = 0.76, 0.63–0.93), community literacy level (high-aOR = 1.31, 1.01–1.71) and community knowledge level of modern contraceptives (high-aOR = 1.37, 1.13–1.67) were found as significant community level factors.

Conclusions

The findings indicate that both individual and community level factors are significantly associated with modern contraceptive use among married women in Senegal. Interventions should focus on enhancing literacy levels of women, their husbands and communities. Furthermore, strengthening awareness and attitude towards family planning should be given priority, especially in rural areas and regions with low resources.

How strong are Malawi's family planning programs for adolescent and adult women? Results of a national assessment of implementation strength conducted by Malawi's National Evaluation Platform

Background

To assess the strength of implementation of family planning programs targeting youth (15-24) in Malawi with a specific focus on youth and the Youth-Friendly Health Services program

Methods

We conducted 9781 mobile phone interviews with facility in-Charge Nurses and health workers (health facility workers, health surveillance assistants [HSAs] and community-based distribution agent [CBDAs]) who provide family planning (FP) services across the 28 districts. Responses were entered in tablet using Open Data Kit. They were summarized and presented using R, Stata (College Station, TX, USA, StatsReport, JHU, Baltimore, MD, USA) and ArcView GIS (ESRI, Redlands, CA, USA).

Results

Availability of key products was a challenge across all health worker types as only 39% of health facilities, 29% of HSAs and 45% of CBDAs had all the FP methods they are supposed to provide on the day of the interview. About 50% of health workers were supervised within past 90 days preceding the study. Despite most facilities saying that they provide youth friendly health services, youth-specific FP guidelines or protocols were not available in 43% of facilities that provide these services and only 33% of facilities had special rooms and 58% have special days for youth.

Conclusions

The commodity supply system needs to ensure that all facilities and workers have a consistent supply of all contraceptive methods. Government and program implementers should ensure availability of all FP guidelines and information, education, communication materials at all service delivery points and facilitate creation of special rooms or days for youth.

Factors associated with use of injectables, long-acting and permanent contraceptive methods (iLAPMs) among married women in Zambia: analysis of demographic and health surveys, 1992-2014

Background

Zambia, with its women having five children on average, is one of the countries in sub-Saharan African with the highest fertility rates. As the country works on expanding its reproductive health programs, this analysis sought to understand factors behind the current utilisation of injectable, long acting and permanent methods (iLAPMs) of contraception.

Methods

Cross-sectional secondary data drawn from the Zambia Demographic and Health Surveys (ZDHS) were used. This included married women aged 15–49 for the years 1992 (n = 620), 1996 (n = 1176), 2001/02 (n = 1483), 2007 (n = 1665) and 2013/14 (n = 4394). Frequencies, cross-tabulations and logistic regression were used to analyse levels and differentials in use of iLAPMs.

Results

Except for the variables “religion” and “region”, the rest of the independent variables show significance on the use of iLAPMs, at varying levels. “Desire for children” is the strongest predictor of use of iLAPMs as it was significant at all the five data points. This is followed by “age”, although it was not significant in 2007. “Education of the woman and partner” and “number of living children” were also significant, but only for two out of the five data collection points. “Ethnicity”, “type of residence”, “heard about FP in last 12 months”, and “main decision maker on woman’s health” were only significant for one out of the five data points.

Conclusion

This study has established that women’s desire for children is the main factor influencing use of iLAPMs in Zambia. Women who still want to have children are less likely to use iLAPMs even though the odds of using these methods among these women increased between 1992 and 2014. This indicates that most of this increase is due to the desire by these women to space births rather than stop having children. The 2013/2014 data also suggest an increase in access to iLAPMs among the less privileged women i.e. those in rural areas and those with low levels of education. This trend appears to have stemmed from the scaling up of family planning programmes to cover rural communities. Greater effort should be invested into family planning programs that reach all categories of women.

Prevalence of unintended pregnancy and associated factors among married women in west Belessa Woreda, Northwest Ethiopia, 2016

Background

Unintended pregnancies can have adverse physical, mental, social, and economic outcomes. Illegal abortions and associated complications often follow unintended pregnancies and claim the lives of many women in developing countries. To better understand how unintended pregnancy impacts married women, this study aimed to assess the prevalence of unintended pregnancies and associated factors among married pregnant women in West Belessa woreda, Ethiopia.

Methods

A community-based cross-sectional study was conducted from August to September 2015.. A multistage stratified sampling technique was used to select nine kebeles, to participate in the study. A total of 619 married pregnant women were selected from these kebeles by the simple random sampling technique and data were collected with a structured questionnaire. Binary logistic regression analysis was used to identify factors associated with the unintended pregnancies. A p-value of < 0.05 in the multi-variable model was used to identify significance.

Result

A total of 592 married pregnant women were surveyed regarding their intention to become pregnant. The prevalence of unintended pregnancy was 13.7%. Age at pregnancy (AOR: 15.2, 95% CI (1.9, 125.2)), history of stillbirth (AOR: 3.3, 95% CI (1.4, 7.9)), discussing pregnancy related issues with husbands (AOR: 2.3, 95% CI (1.1, 5.0)), making family planning decisions on their own (AOR: 0.4, (0.2, 0.8)), and making family planning decisions with their husbands (AOR: 95% CI 0.2 (0.1, 0.4)) were significantly associated with unintended pregnancies in this group.

Conclusion

The magnitude of unintended pregnancy in the study area was low. Age at pregnancy, history of stillbirth and involvement of partners in making reproductive health choices were associated with unintended pregnancies. Empowering women to make family planning decisions and increasing partner involvement in reproductive health could decrease unintended pregnancies.

Abortion history and its association with current use of modern contraceptive methods in Luanda, Angola

BACKGROUND

Women in sub-Saharan Africa often use abortion as a method of limiting their fertility and spacing births. However, it is not well understood whether having an abortion influences contraceptive behavior. The goal of this study was to examine associations between abortion history and use of a modern contraceptive method among women in Luanda, Angola.

MATERIALS AND METHODS

We analyzed data on 1,176 women aged 15-49 years from a 2012 cross-sectional study conducted in Luanda, Angola, which aimed to obtain general information on sexual and reproductive health indicators. The outcome and exposure were based on participant reports of past induced abortions and current use of a modern method. We used a modified Poisson regression with robust standard errors to estimate the relative risks of using a modern contraceptive method, given history of induced abortion.

RESULTS

Among all respondents, 736 (62.6%) reported using a modern contraceptive method. The clear majority of the respondents (73.21%), regardless of abortion history, were using either no method, a traditional method, or condoms. Long-acting reversible contraceptive use was very low across all respondents (2.73%). The most common family planning method reported by women with a history of abortion was condoms (32.76%). Regression analysis demonstrated that women who had a history of abortion were 1.23 times more likely to use a modern contraceptive method as compared to those who never had an abortion (relative risk: 1.23; 95% CI: 1.10-1.36), after adjusting for potential confounders. Postregression estimations of predicted probabilities demonstrated that women with a history of abortion had an 80% probability of using a modern method (95% CI: 0.76-0.84), while those who never had an abortion had a 60% probability of using a modern method (95% CI: 0.59-0.61).

CONCLUSION

History of induced abortion was associated with use of a modern contraceptive method in our study population. The most common contraceptive used by women with a history of induced abortion was condoms, indicating that despite adoption of a modern method, many women are still at risk for an unintended pregnancy. Further research is needed to understand the causal factors underlying women's postabortion contraceptive choices.