Contraceptive Method Mix: Updates and Implications

Assessing Acceptability of Biodegradable Contraceptive Implants in Kenya and Senegal

BACKGROUND

Contraceptive implants are popular in Africa, but barriers to removal exist. Biodegradable implants (BDIs) offer an alternative to the need for removal. This study explored potential user, provider, and other stakeholder perspectives on 2 BDI prototypes, revealing opportunities and challenges for introduction.

METHODS

We conducted focus group discussions (FGDs) and in-depth interviews (IDIs) with women, men, family planning (FP) providers, community influencers, and FP policymakers and program staff in Kenya and Senegal. Characteristics of the 2 BDI prototypes were shared, and participants held and interacted with placebo prototypes. Structural coding was used to analyze the data focused on key product attributes, including biodegradation, removal potential, size, material, insertion site, and duration of effectiveness.

RESULTS

We conducted 16 FGDs and 35 IDIs with 106 participants in Kenya and 15 FGDs and 43 IDIs with 102 participants in Senegal. Overall, respondents liked the idea of a BDI, noting the avoidance of pain and scarring and reduced transport and costs as benefits of no removal requirement. Kenyan respondents expressed greater understanding of the biodegradation process than those in Senegal, though potential users in both countries expressed concerns about possible side effects associated with the process. In Senegal, mention of cholesterol in a BDI caused concern, while Kenyan participants responded positively to the same BDI being composed of organic materials. The second BDI product was viewed as more similar to existing implants, which providers preferred. Participants suggested increasing the pregnancy protection duration beyond 18 months. No clear preference between products emerged, and participants liked and disliked some characteristics of both.

CONCLUSIONS

Kenyan and Senegalese participants expressed interest in the BDI concept but expressed some reservations related to biodegradation, material, and side effects. BDIs offer the opportunity to expand contraceptive choice. However, messaging around product characteristics will be required for successful introduction and uptake.

Mobilizing stakeholders for implant removals in Burkina Faso using landscape assessment data

BACKGROUND

Successful efforts to encourage uptake of subdermal contraceptive implants, with a lifespan of three to five years, necessitate planning to ensure that quality removal services are available when desired. In Burkina Faso, implant use has tripled over the past 8 years and now comprises almost half of the contraceptive method mix. Population Monitoring for Action (PMA) surveys identified barriers to obtaining quality removal when desired, particularly when the implant is not palpable, or providers lack needed skills or supplies. The Expanding Family Planning Choices (EFPC) project supported ministries of health in four countries with evaluation and strengthening of implant removal services.

METHODS

An implant removal landscape assessment was conducted at 24 health facilities in three regions of Burkina Faso with high implant use that included provider observations of implant removal, interviews with providers and health facility managers, and facility readiness surveys. The project used landscape data to mobilize stakeholders through a series of participatory workshops to develop a collaborative roadmap and commit to actions supporting quality implant removals.

RESULTS

Landscape findings revealed key gaps in provision of quality removal services, including high levels of provider confidence for implant insertion and removal (82% and 71%, respectively), low competence performing simple and difficult removals (19.2% and 11.1%, respectively), inadequate supplies and equipment (no facilities had all necessary materials for removal), lack of difficult removal management systems, and a lack of standard data collection tools for removal. Exposure to the data convinced stakeholders to focus on removals rather than expanding insertion services. While not all roadmap commitments were achieved, the process led to critical investments in quality implant removals.

CONCLUSION

Landscape data revealed that facilities lack needed supplies and equipment, and providers lack skills needed to perform quality implant removals, limiting client reproductive choice. Disseminating this data enabled stakeholders to identify and commit to evidence-based priority actions. Stakeholders have since capitalized on program learnings and the roadmap, including following MOH guidance for implant removal supplies and health provider training. Our experience in Burkina Faso offers a replicable model of how data can direct collective action to improve quality of contraceptive implant removals.

Access to quality contraceptive counselling among adolescent girls and young women in sub-Saharan Africa

BACKGROUND

Improving women's access to and use of modern contraceptives is a key global strategy for improving the sexual and reproductive health of women. However, the use of modern contraceptives among adolescent girls and young women in sub-Saharan Africa (SSA) remains relatively low, despite the numerous interventions to increase patronage. This study examined adolescent girls and young women's receipt of quality contraceptive counselling and its associated factors in SSA.

METHODS

Data for the study were extracted from the recent Demographic and Health Surveys of 20 countries in SSA, spanning from 2015 to 2021. A sample of 19,398 adolescent girls and young women aged 15 to 24 years was included in the study. We presented the proportion of adolescent girls and young women who received quality contraceptive counselling using a spatial map. Multilevel binary logistic regression analysis was carried out to examine the factors associated with the receipt of quality contraceptive counselling.

RESULTS

Overall, 33.2% of adolescent girls and young women had access to quality contraceptive counselling, ranging from 13.0% in Cameroon to 67.0% in Sierra Leone. The odds of receiving quality contraceptive counselling was higher among adolescent girls and young women aged 20-24 (AOR = 1.48, CI: 1.32-1.67), those with primary (AOR = 1.32, CI: 1.11-1.57) and secondary or higher education (AOR = 1.31, CI: 1.09-1.58), and those married (AOR = 1.32, CI: 1.15-1.52), cohabiting (AOR = 1.47, CI: 1.23-1.76), and previously married (AOR = 1.48, CI: 1.20-1.83) compared to their counterparts in the reference groups. Adolescent girls and young women who were currently working (AOR = 1.22, CI: 1.09-1.37), those who heard of family planning from radio in the last few months (AOR = 1.34, CI:1.21-1.50), those who visited the health facility in the last 12 months (AOR = 1.69, CI: 1.52-1.88), and those residing in the Southern (AOR = 5.01, CI: 3.86-6.51), Eastern (AOR = 2.54, CI: 1.96-3.30), and Western (AOR = 4.09, CI: 3.19-5.25) SSA were more likely to receive quality contraceptive counselling compared to their counterparts in the reference groups. Conversely, adolescent girls and young women who used the internet, those who had problem getting permission to seek medical help, those facing problem in seeking medical help for not wanting to go alone, those from the middle and richest wealth indices, and those from the rural areas were less likely to receive quality contraceptive counselling compared to their counterparts in the reference groups.

CONCLUSION

Receipt of quality contraceptive counselling among adolescent girls and young women was low. Considering the importance of quality contraceptive counselling on the uptake and continuation of contraception, policymakers need to institute measures that improve adolescent girls and young women's access to quality contraceptive counselling in SSA, especially in countries like Cameroon, Angola, Madagascar, Mauritania, and Guinea, taking into consideration the factors identified in the study. Increasing adolescent girls and young women's access to quality contraceptive counselling could greatly minimize the risk of unintended pregnancies and its associated maternal and child health burden in SSA and subsequently contribute to the attainment of the Sustainable Development Goal 3, target 3.7.

Adjusting Injectable Contraceptive Use for Months Since the Last Injection

Injectables are one of the most popular methods of contraception worldwide, particularly in sub-Saharan Africa. An advantage of injectables over shorter-acting methods is that they provide additional flexibility by not requiring re-supply as frequently. However, there is a risk that injectable users may delay their next injection and may therefore have reduced or no protection from pregnancy. In surveys, women may report that they are using contraception in the form of injectables when the time since they had their last injection (more than four months) would imply that they have reduced protection against the risk of pregnancy. We carried out two field studies in urban Malawi, and we record reported injectable contraceptive use while also asking the number of months since women received their last injection. We observe that 13.8 percent of women who report using injectables also report that they received their last injection more than four months ago, and 11 percent report that they received their last injection more than six months ago. Our analysis highlights the need for additional follow-up with women who report using injectables in surveys to confirm whether they are, in fact, using the method effectively.

[Contraceptive mix and factors associated with the type of method used by Brazilian women: a population-based cross-sectional study]

This study aims to describe the contraceptive mix and analyze the factors associated with the type of contraceptive used by Brazilian women of reproductive age. This is a cross-sectional, population-based study with data from 19,962 women aged 15 to 49 years. The outcomes were use and type of contraceptive, classified as: short-acting reversible contraceptives (SARC), long-acting (LARC), and permanent. The explanatory variables were characteristics of reproductive history, sociodemographic history, and access to health services. Multinomial logistic regression was used for odds ratio (OR) estimates, with SARC being the reference category. The analyses were performed in the Survey module of the Stata software, which considered the effect of the complex sampling plan of the 2019 Brazilian National Health Survey. The prevalence of contraceptive use was 83.7%. Of the total number of users, 72% used SARC, 23.2% permanent methods, and 4.8% LARC. Women with higher education, health insurance, who had deliveries, and who participated in reproductive planning groups had a higher chance of using LARC when compared with the use of SARC, while registration at the basic health unit was associated with a lower chance of use. Still, the higher the age and parity, in addition to living with the partner, the greater the chance of using permanent methods in relation to the use of SARC. Despite the high coverage of contraception, the contraceptive mix remains obsolete, with a predominance of the use of SARC. In addition, important inequalities in access were observed, with LARC being accessible only to women with better socioeconomic conditions, while permanent methods were associated with a profile of greater social vulnerability.

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.

"Every Medicine Is Somewhat Poisonous": Understanding the reluctance to use oral contraceptives among unmarried women seeking abortion in China

OBJECTIVES

In this study, I examined the low uptake of oral contraceptives (OCs) in China and the factors affecting the reluctance among unmarried Chinese women seeking abortion to use OCs to prevent unintended pregnancies.

STUDY DESIGN

I conducted ethnographic and participant observation in multiple medical facilities and interviewed 62 women who were seeking or had had an abortion between 2013 and 2017 in a coastal city in east China. I analyzed data regarding the women's perceptions and experiences of using OCs through a thematic analysis approach.

RESULTS

The women reported fear of side effects, including infertility, weight gain, and mental health issues and their view on traditional Chinese medicine further validated their skepticism toward Western medicine. Discouragement from male partners and a lack of sexual and reproductive education also caused their hesitancy and misunderstandings of OCs.

CONCLUSIONS

This study contributes to a more nuanced understanding of the barriers to OC use in China. It resonates with existing studies that associate the reluctance to use OCs with the fear of side effects and highlights the influence of sociocultural specificities and couple interactions in shaping contraceptive use.

IMPLICATIONS

Tackling premarital abortions is one of the priorities of the Chinese government in the face of the population crisis. Service providers and educators should understand unmarried women's reluctance to use OCs and provide comprehensive sexuality education and postabortion counseling services to women and men to dispel culturally specific misconceptions.

Down But Not Out: Vasectomy Is Faring Poorly Almost Everywhere-We Can Do Better To Make It A True Method Option

INTRODUCTION

Demand for vasectomy-1 of 2 contraceptive methods for men-has been low, with deep-seated myths, misconceptions, and provider bias against it widespread. Programmatic attention and donor funding have been limited and sporadic.

METHODS

We analyzed vasectomy use in 84 low- and middle-income countries (LMICs) plus the 11 high-income countries with vasectomy prevalence above 1%. These 95 countries comprise 90% of the world's population. Data come from United Nations survey compilations, population estimates, and gender inequality rankings. We also reviewed recent articles on vasectomy and analyses of chronic challenges to vasectomy service provision.

RESULTS

Vasectomy use is 61% lower now than 2 decades ago. Of 922 million women using contraception worldwide, 17 million rely on vasectomy-27 million fewer than in 2001. In contrast, 219 million women use tubectomy-8 million more than in 2001. Of 84 LMICs, 7 report vasectomy prevalence above 2%. In 56 LMICs, no more than 1 in 1,000 women relies on vasectomy. Female-to-male disparities in permanent method use widened globally, from 5:1 to 13:1, and are much higher in some regions and countries (e.g., 76:1 in India). Countries with the highest vasectomy prevalence are among those with the highest gender equality and vice versa.

CONCLUSION

Vasectomy use is surprisingly low globally and declining. Use remains negligible in almost all LMICs, reflecting low demand and program priority. For vasectomy to become an accessible, rights-based option, program efforts need to be holistic, ensuring an enabling environment while coordinating demand- and service-focused efforts. Vasectomy champions at all levels should be supported on a sustained basis. On the demand side, harnessing mass and social media to increase accurate knowledge and normalize vasectomy as a method and service will be particularly valuable. Evidence from Bolivia suggests relatively few trained providers and procedures could result in a country's attaining 1% vasectomy prevalence.

Contraceptive Continuation and Experiences Obtaining Implant and IUD Removal Among Women Randomized to Use Injectable Contraception, Levonorgestrel Implant, and Copper IUD in South Africa and Zambia

Few longitudinal studies have measured contraceptive continuation past one year in sub-Saharan Africa. We surveyed 674 women who had been randomized to receive the three-month intramuscular contraceptive injectable (DMPA-IM), levonorgestrel (LNG) implant, or copper intrauterine device (IUD) during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial in South Africa and Zambia and were subsequently followed for two additional years to explore method continuation, reasons for discontinuation, and access to implant and IUD removal services. We also conducted in-depth qualitative interviews with 39 participants. We estimated cumulative discontinuation probabilities using Kaplan-Meier estimates and assessed factors associated with discontinuation using Cox-proportional hazards models. The LNG implant continuation rate over the maximum 44-month study period was 60 percent, while rates for the copper IUD and DMPA-IM were 52 percent and 44 percent, respectively. Reasons for method discontinuation included side effects, particularly menstrual changes, and method stock-outs. Most implant and IUD users who sought removal were able to access services; however, room for improvement exists. In this cohort originally randomized to receive a contraceptive method and attend regular study visits, implants and IUDs continued to be highly acceptable over an additional two years, but facilities should continue to ensure that insertions and removals are available as requested.

Trends in contraceptive method mix among adolescents and youth aged 15-24 in low- and middle-income countries

Background

Method mix - the percent distribution of contraceptive use by method among contraceptive users - reflects both client choice of method and method availability. In a country where clients have access to a wide range of methods at an affordable price, method mix is a strong proxy for method choice. In contrast, where access is limited by numerous factors - method availability, cost, or provider attitudes - method mix may not capture method choice well. Given that method mix can be measured reliably from population-based surveys, it is useful in exploring method choice. While the method mix for all women of reproductive age (15-49 years) has been described previously, the method mix for adolescents and young women aged 15-24 remains unexplored despite this population's high risk for unintended pregnancy.

Objectives

This study investigates the contraceptive method mix for women aged 15-24 in low- and middle-income countries (LMICs) with national survey data and describes how the method mix differs by age group, geographic region, and marital status for women.

Methods

Using data from the Demographic and Health (DHS) Surveys, the contraceptive method mix among women aged 15-24 across 64 LMICs is analyzed by age, marital status, and region, with measures of skew and average deviation. Three case studies are presented in which the trend over time in the method mix is examined.

Results

There are large variations in method mixes across regions, which reflect their differences in various supply and demand constraints. However, there is consistently high usage of short-acting methods among both age groups, 15-19 and 20-24, compared to the full population of all women of reproductive age. Male condoms overwhelmingly predominate as the method used by women 15-24 in all regions.

Conclusion

The marked differences found by marital status, region, and age show the need for programs to be tailored to local circumstances. Additionally, the large unmet need for contraception signals the ongoing urgency for strengthened programmatic efforts, and for a wider offering of methods to enlarge the choices available to young women. Unmarried women in particular deserve attention, as well as young married women who wish to postpone a pregnancy.

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.

Making Removals Part of Informed Choice: A Mixed-Method Study of Client Experiences With Removal of Long-Acting Reversible Contraceptives in Senegal

BACKGROUND

Ensuring access to removal services for implants and intrauterine devices (IUDs) is essential to realize informed choice and voluntary family planning. We document removal desires and experiences among women who received an implant or IUD from the public sector in 3 districts of Senegal.

METHODS

We conducted a phone survey of 1,868 implant and IUD users, 598 follow-up surveys with those who had ever asked a provider for a removal, and 24 in-depth interviews (IDIs) with women who had ever wanted an implant removal. We analyzed survey data descriptively and IDI data thematically.

RESULTS

Fifty-eight percent of implant users and 54% of IUD users reported having wanted a removal. Desired pregnancy and contraceptive-induced menstrual changes (CIMCs) were the main reasons for removal desires. Fifty-four percent of implant users and 55% of IUD users who asked a provider for a removal reported challenges accessing services, with over two-thirds noting long lines or wait times. Sixty-three percent of implant users and 73% of IUD users who saw a provider were satisfied with the outcome of their first interaction. Over 90% of participants had not been told about the removal cost at insertion. Almost all participants who had their method removed obtained a complete removal during their first clinical procedure. Around two-thirds of participants who obtained a removal did not take up another method at that time. IDIs confirmed the influence of CIMCs on removal desires and show some partner influence is common in removal decision making. Barriers include lack of available qualified providers and supplies. Provider interactions play an important role in satisfaction with removal services.

CONCLUSION

Participants' experiences accessing removal services were generally positive. Areas of potential improvement include client flow, counseling messages at insertion, and when advising clients to keep their method, pricing, and post-removal reinsertion or method switching.

Providers' views on hormonal family planning methods: a qualitative study from Dosso, Niger

Background: Family planning (FP) providers play an important role in ensuring that clients are offered a full range of FP methods. This qualitative study explores providers' views on three hormonal FP methods and why they think women may choose these methods in Niger.                                                    Methods: In-depth interviews were conducted with 24 FP providers in 24 government health centers in Dosso region, Niger between February-March 2020. Providers were asked about the suitability of different FP methods for women, including adolescents and married women with children. The interviews were translated and transcribed from Hausa and Zarma into French, thematically coded, and qualitatively analyzed. Results: Many providers believed discretion to be the most important method attribute for women. Providers report preferring implants for young clients because of the more rapid return to fertility. They disagreed on whether implants or injectables are more discrete for clients. That said, providers felt that clients appreciate the implant's discretion, effectiveness, long-acting nature, and simplicity of use.  Providers perceived that the majority of women choose injectables due to familiarity with the method, the fact that it is "invisible" to an outsider, and a lack of awareness of implants. Providers stated that while women may not initially choose the implant, when given more information about it, they were more open to adopting it, or switching from another method, and less likely to believe local myths. Providers believed that women find pills to be indiscreet. Conclusions: The findings highlight that while providers have perspectives on suitable methods for certain women, they also recognize that clients have their own preferences, such as how discreet the method is. As programs continue to expand method choice and new contraceptive technologies undergo research and development, highly desirable features such as discretion need to be considered.

Providers' views on hormonal family planning methods for young women: a qualitative study from Dosso, Niger

Background: Family planning (FP) providers play an important role in ensuring that clients are offered a full range of FP methods. This qualitative study explores providers' views on three hormonal FP methods and why they think young women may choose these methods in Niger.                                                     Methods: In-depth interviews were conducted with 24 FP providers in 24 government health centers in Dosso region, Niger between February-March 2020. Providers were asked about the suitability of different FP methods for women, including unmarried adolescents and young married women with children. The interviews were translated and transcribed from Hausa and Zarma into French, thematically coded, and qualitatively analyzed. Results: Many providers believed discretion to be the most important method attribute for women. Providers report preferring implants for young clients because of the more rapid return to fertility. They disagreed on whether implants or injectables are more discrete for clients. That said, providers felt that clients appreciate the implant's discretion, effectiveness, long-acting nature, and ease of use.  Providers perceived that the majority of women choose injectables due to familiarity with the method, the fact that it is "invisible" to an outsider, and a lack of awareness of implants. Providers stated that while women may not initially choose the implant, when given more information about it, they were more open to adopting it, or switching from another method, and less likely to believe local myths. Providers believed that women find pills to be indiscreet. Conclusions: The findings highlight that while providers have perspectives on suitable methods for certain women, they also recognize that clients have their own preferences, such as how discreet the method is. As programs continue to expand method choice and new contraceptive technologies undergo research and development, highly desirable features such as discretion need to be considered.

Examining Adult E-cigarette Use in Kentucky and Its Appalachian Region Using the Behavioral Risk Factor Surveillance System, 2016-2017

OBJECTIVES

Electronic cigarette (e-cigarette) use has increased steadily in the United States, but little research has examined its prevalence in states comprising Appalachia, a rural region known for high rates of tobacco use. This study assessed lifetime and current e-cigarette use among adults by sociodemographic characteristics, geographic region, and cigarette smoking in Kentucky, with a focus on the Appalachian region.

METHODS

We used data from the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys to calculate the prevalence of lifetime and current e-cigarette use, and we used weighted multivariable logistic regression analyses to examine the relative influence of other factors.

RESULTS

Among adults in Kentucky, 5.8% (95% CI, 5.2%-6.4%) were current e-cigarette users and 27.0% (95% CI, 25.9%-28.0%) were lifetime users, compared with state medians of 4.6% (95% CI, 4.0%-5.1%) and 21.4% (95% CI, 19.4%-23.5%) for the United States. Multivariable regression models showed similar patterns for all regions: higher prevalence odds of current e-cigarette use among adults aged 18-24, current conventional smokers, and adults unable to work. Generally, Appalachian residents of Kentucky did not have significantly higher rates of lifetime or current e-cigarette use as compared with other non-Appalachian residents of Kentucky. Hispanic residents of Appalachian Kentucky, however, had higher rates of e-cigarette use than Hispanic residents of other regions of Kentucky.

CONCLUSIONS

Rates of e-cigarette use were higher in Kentucky than in the United States but were not further elevated in Kentucky's Appalachian region. High rates of e-cigarette use among Hispanic residents of Appalachia indicate a need to focus future interventions in the region.

Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Meeting the contraceptive needs of women of reproductive age is beneficial for the health of women and children, and the economic and social empowerment of women. Higher rates of contraceptive coverage have been linked to the availability of a more diverse range of contraceptive methods. We present estimates of the contraceptive prevalence rate (CPR), modern contraceptive prevalence rate (mCPR), demand satisfied, and the method of contraception used for both partnered and unpartnered women for 5-year age groups in 204 countries and territories between 1970 and 2019.

METHODS

We used 1162 population-based surveys capturing contraceptive use among women between 1970 and 2019, in which women of reproductive age (15-49 years) self-reported their, or their partner's, current use of contraception for family planning purposes. Spatiotemporal Gaussian process regression was used to generate estimates of the CPR, mCPR, demand satisfied, and method mix by age and marital status. We assessed how age-specific mCPR and demand satisfied changed with the Socio-demographic Index (SDI), a measure of social and economic development, using the meta-regression Bayesian, regularised, trimmed method from the Global Burden of Diseases, Injuries, and Risk Factors Study.

FINDINGS

In 2019, 162·9 million (95% uncertainty interval [UI] 155·6-170·2) women had unmet need for contraception, of whom 29·3% (27·9-30·6) resided in sub-Saharan Africa and 27·2% (24·4-30·3) resided in south Asia. Women aged 15-19 years (64·8% [62·9-66·7]) and 20-24 years (71·9% [68·9-74·2]) had the lowest rates of demand satisfied, with 43·2 million (95% UI 39·3-48·0) women aged 15-24 years with unmet need in 2019. The mCPR and demand satisfied among women aged 15-19 years were substantially lower than among women aged 20-49 years at SDI values below 60 (on a 0-100 scale), but began to equalise as SDI increased above 60. Between 1970 and 2019, the global mCPR increased by 20·1 percentage points (95% UI 18·7-21·6). During this time, traditional methods declined as a proportion of all contraceptive methods, whereas the use of implants, injections, female sterilisation, and condoms increased. Method mix differs substantially depending on age and geography, with the share of female sterilisation increasing with age and comprising more than 50% of methods in use in south Asia. In 28 countries, one method was used by more than 50% of users in 2019.

INTERPRETATION

The dominance of one contraceptive method in some locations raises the question of whether family planning policies should aim to expand method mix or invest in making existing methods more accessible. Lower rates of demand satisfied among women aged 15-24 years are also concerning because unintended pregnancies before age 25 years can forestall or eliminate education and employment opportunities that lead to social and economic empowerment. Policy makers should strive to tailor family planning programmes to the preferences of the groups with the most need, while maintaining the programmes used by existing users.

FUNDING

Bill & Melinda Gates Foundation.

Barriers to male condom use in Rohingya refugee camps in Bangladesh: A qualitative study

Background

Rohingya people are often called the most persecuted minority in the world. Currently, almost 800,000 Rohingya refugees live in temporary shelters in Cox's Bazar, Bangladesh. More than one-quarter of them are women and girls of reproductive age who are at increased risk of unplanned pregnancies, unsafe abortions and related complications. However, the use of contraception remains inadequate, and particularly use of condoms and male participation is scarce. This study examines the barriers to condom use as a contraceptive method among married Rohingya couples.

Methods

We conducted in-depth qualitative interviews of married Rohingya men and women and thematically analysed the data.

Findings

Depo Provera injections and pills are the dominant forms of contraception. Men's participation in family planning and contraceptive use is rare, and so is the use of condoms. Participants identified several barriers to condom use, including contraception being the responsibility of the women, socio-cultural issues, the stigma attached to condoms, unfamiliarity with condoms, the limitations of condoms, and issues of security in conjugal life. Health workers do not promote condoms in the same way as other contraceptive methods.

Interpretation

Condom use and men's participation in contraception use are rare in Rohingya camps. The involvement of family planning workers who are males may help to promote the use of condoms and increase the method-mix options of contraceptives.

Funding

La Trobe University, Melbourne, Australia.

Contextual factors associated with contraceptive utilization and unmet need among sexually active unmarried women in Kenya: A multilevel regression analysis

Background

Unmarried women who report less recent sexual intercourse (>30 days from survey enumeration) are largely excluded from global health monitoring and evaluation efforts. This study investigated level and contextual factors in modern contraceptive utilization and unmet need within this overlooked female subpopulation in Kenya from 2014 to 2019.

Methods

This study analyzed data from the Performance Monitoring and Accountability (PMA) survey in Kenya, a nationally representative survey of female respondents, to understand the level and contextual factors for family planning utilization and unmet need within female subgroups including married, unmarried sexually active (defined as sexual intercourse within 30 days of survey enumeration), and unmarried with less recent sexual intercourse (defined as sexual intercourse 1–12 months prior to survey enumeration). The analysis included multilevel regression modeling to assess correlates on outcomes of modern contraceptive prevalence rate (mCPR), unmet need, and recent emergency contractive pill (ECP) use, which is a unique PMA question: “Have you used emergency contraception at any time in the last 12 months?”.

Results

Cumulatively, the surveys enumerated 19,161 women and this weighted analysis included 12,574 women aged 15–49 from three female subgroups: 9,860 married women (78.4%), 1,020 unmarried sexually active women (8.1%), and 1,694 unmarried women with less recent sexual intercourse (13.5%). In 2019, while controlling for covariates, unmarried women with less recent sexual intercourse exhibited statistically significant differences (p-value<0.02) in current mCPR, mCPR at last sexual intercourse, unmet need for modern contraceptives, and recent ECP use. As compared to an unmarried woman with less recent sexual intercourse (i.e., reported sex 1–12 months prior to survey), the odds of an unmarried sexually active woman (i.e., reported sex within last 30 days of survey) currently using modern contraceptives was 2.28 (95% CI: 1.64, 3.18), using modern contraceptives at last sexual intercourse was 1.44 (95% CI: 1.06, 1.95), and having an unmet need for modern contraceptives was 2.01 (95% CI: 1.29, 3.13) while controlling for covariates. The odds of a married woman using ECP during the last 12 months was 0.60 (95% CI: 0.44, 0.82) as compared to an unmarried woman with less recent sexual intercourse. In 2019, unmarried women with less recent sexual intercourse reported the highest rate of ECP use during the last 12 months at 13.5%, which was similar for unmarried sexually active women at 13.3%. Since 2014, summary measures of unmet need and total demand for modern contraceptives increased for unmarried women with less recent sexual intercourse, but declined for the other female subgroups.

Conclusion

In Kenya, unmarried women with less recent sexual intercourse exhibited significantly different contraceptive utilization, unmet need, and recent emergency contraceptive use. Moreover, changes over time in key family planning indicators were asymmetrical by female subgroup. This study identifies an important monitoring gap regarding unmarried women with less recent sexual intercourse. Evidence dissemination by the global measurement community for these unmarried women is exceedingly scarce; therefore, developing an inclusive research agenda and actionable information about these marginalized women is needed to enable targeted planning and equitable service delivery.

Effects of a multimedia campaign on HIV self-testing and PrEP outcomes among young people in South Africa: a mixed-methods impact evaluation of 'MTV Shuga Down South'

Introduction

Innovative HIV technologies can help to reduce HIV incidence, yet uptake of such tools is relatively low among young people. To create awareness and demand among adolescents and young adults, a new campaign of the pan-African MTV Shuga series (‘Down South 2’; DS2), featured storylines and messages about HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) through television, radio and accompanying multimedia activities in 2019–2020.

Methods

We conducted a mixed-methods evaluation of the new MTV Shuga series among 15–24 years old in Eastern Cape, South Africa, in 2020. Quantitative and qualitative methods were used to investigate complementary evaluations questions, namely, whether and how the DS2 campaign works. A web-based survey, promoted via social media platforms of schools, universities and communities, assessed exposure to MTV Shuga and knowledge of HIV status; secondary outcomes included awareness and uptake of HIVST and PrEP. We used multivariable logistic regression to estimate associations between exposure to DS2 and each outcome, adjusting for sociodemographic factors, media assets and exposure to other media campaigns. An embedded qualitative evaluation explored mechanisms of DS2’s impact through deductive and inductive thematic analysis of in-depth individual and group interviews.

Results

Among 3431 online survey participants, 43% had engaged with MTV Shuga and 24% with DS2 specifically. Knowledge of HIV status was higher among those exposed to DS2 (71%) vs those who were not (39%; adjusted OR=2.26 (95% CI 1.78 to 2.87)). Exposure was also associated with increased awareness of HIVST (60% vs 28%; aOR=1.99 (1.61 to 2.47)) and use of HIVST (29% vs 10%; aOR=2.49 (1.95 to 3.19)). One-third of respondents were aware of PrEP, with higher proportions among those exposed versus non-exposed to DS2 (52% vs 27%; aOR=1.90 (1.53 to 2.35)). Qualitative insights identified mechanisms by which DS2 increased awareness, confidence and motivation to use HIVST and PrEP, but had less influence on service access.

Conclusions

We found evidence consistent with a positive causal impact of the MTV Shuga DS2 campaign on HIV prevention outcomes among young people in a high-prevalence setting. As diverse testing and PrEP technologies become accessible, an immersive edutainment campaign can help to expand HIV prevention choices and close age and gender gaps in HIV testing and prevention goals.

A New Contraceptive Diaphragm in Niamey, Niger: A Mixed Methods Study on Acceptability, Use, and Programmatic Considerations

Through a pilot introduction in Niamey, Niger, we found that expanding method options to include the Caya diaphragm, a new self-care contraceptive product without side effects for most users, may address some of the challenges that contribute to very low contraceptive use.

Introduction:

Methods:

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Contraceptive Method Skew in India 1992-2016: Analysis Using a New Method Skew Index

This paper analyses method skew in India over more than two decades using a new method skew index. The analysis reveals clear regional pattern in method skew in the country. In north and east regions of the country, method skew is average and below average, but it is high or very high in the south region. We investigate roles of such factors as poverty, education, social class, and religion in deciding the method skew at the district level using the classification modeling approach and find that the roles of these factors are different in different regions of the country. An important finding of the analysis is that there is a positive correlation between the degree of the method skew and contraceptive prevalence at the district level.

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.

Declining yet persistent use of traditional contraceptive methods in low- and middle-income countries

Traditional contraceptive methods are used by 55 million women in developing countries. This study analysed over 80 national surveys to compare traditional with modern method users, by type, region, socio-demographic characteristics, strength of family planning programmes and discontinuation rates. The advance of modern methods has greatly reduced the share held by traditional methods, but the actual prevalence of their use has declined little. Young, sexually active unmarried women use traditional contraception much more than their married counterparts. Discontinuation rates are somewhat lower for traditional methods than for the resupply methods of the pill, injectable and condom; among users of all of these methods, more than a quarter stop use in the first year to switch to alternative methods. Traditional method use is firmly entrenched in many countries, as the initial method tried, a bridge method to modern contraception and even the primary method where other methods are not easily available.