Characterizing provider bias in contraceptive care in Tanzania and Burkina Faso: A mixed-methods study

Provider bias based on age, marital status, and parity may be a barrier to quality contraceptive care. However, the extent to which bias leads to disparities in care quality is not well understood. In this mixed-methods study, we used four different data sources from the same facilities to assess the extent of bias and how much it affects contraceptive care. First, we surveyed providers in Tanzania and Burkina Faso (N = 295) to assess provider attitudes about young, unmarried, and nulliparous clients. Second, mystery clients anonymously visited providers for contraceptive care and we randomly assigned the reported age, marital status, and parity of each visit (N = 306). We used data from these visits to investigate contraceptive care disparities across 3 domains: information provision and counseling quality, contraceptive method provision, and perceived treatment. Third, we complemented mystery client data with client exit surveys (N = 31,023) and client in-depth interviews (N = 36). In surveys, providers reported biased attitudes against young, unmarried, and nulliparous clients seeking contraceptives. Similarly, we found disparities according to these characteristics in the reporting of contraceptive care quality; however, we found that each characteristic affected a different quality of care domain. Among mystery clients we found age-related disparities in the provision of methods; 16/17-year-old clients were 18 and 11 percentage points less likely to perceive they could take a contraceptive method relative to 24-year-old clients in Tanzania and Burkina Faso, respectively. Unmarried mystery clients perceived worse treatment from providers compared to married clients. Nulliparous mystery clients reported lower quality contraceptive counseling than their parous counterparts. These results suggest that clients of different characteristics likely experience bias across different elements of care. Improving care quality and reducing disparities will require attention to which elements of care are deficient for different types of clients.

Assessing quality of family planning counseling and its determinants in Kenya: Analysis of health facility exit interviews

Background

Available evidence suggests that provision of quality of care in family planning services is crucial to increasing uptake and continuation of use of contraception. Kenya achieved a modern contraceptive prevalence rate of 60% in 2018, surpassing its 2020 target of 58%. With the high prevalence, focus is geared towards improved quality of family planning services. The objective of this study is to examine the quality of family planning counseling and its associated factors in health facilities in Kenya.

Methods

We conducted a secondary analysis of the 2019 Kenya Performance Monitoring and Action, client exit data of women who had received family planning services. Quality of counseling was assessed using the Method Information Index Plus. We conducted a multivariable ordinal logistic regression analysis of data from 3,731 women to establish determinants of receiving quality family planning services.

Results

The Method Information Index Plus score for higher-quality counseling was 56.7%, lower-quality counseling 32.4%, and no counseling 10.9%. Women aged 15–24 years (aOR = 0.69, 95% CI = 0.56–0.86, p = 0.001) had lower odds of receiving better counseling compared to women aged 35 years and above. Those with no education (aOR = 0.52, 95% CI = 0.33–0.82, p = 0.005), primary (aOR = 0.56, 95% CI = 0.44–0.71, p<0.001) and secondary (aOR = 0.79, 95% CI = 0.65–0.98, p = 0.028) were less likely to receive better counseling compared to those with tertiary education. Women who received long acting and reversible contraception methods (aOR = 1.75, 95% CI = 1.42–2.17, p<0.001), and those who were method switchers (aOR = 1.24, 95% CI = 1.03–1.50, p = 0.027), had a higher likelihood of receiving better quality of counseling as compared to those on short-term methods and those who were continuers, respectively.

Conclusion

The quality of family planning counseling in Kenya is still sub-optimal considering that some women receive no form of counseling at service delivery point. There is need to review the existing FP guidelines and training packages to increase focus on the quality of counseling services offered by health providers. Social accountability strategies that empower women to demand quality services should be included in community-level family planning interventions.

Measuring quality of family planning counselling and its effects on uptake of contraceptives in public health facilities in Uttar Pradesh, India: A cross-sectional analysis

BACKGROUND

Quality of care in family planning traditionally focuses on promoting awareness of the broad array of contraceptive options rather than on the quality of interpersonal communication offered by family planning (FP) providers. There is a growing emphasis on person-centered contraceptive counselling, care that is respectful and focuses on meeting the reproductive needs of a couple, rather than fertility regulation. Despite the increasing global focus on person-centered care, little is known about the quality of FP care provided in low- and middle- income countries like India. This study involves the development and psychometric testing of a Quality of Family Planning Counselling (QFPC) measure, and assessment of its associations with contraceptives selected by clients subsequently.

METHODS

We analyzed cross-sectional survey data from N = 237 women following their FP counselling in 120 public health facilities (District Hospitals and Community Health Centers) sampled across the state of Uttar Pradesh in India. The study captured QFPC, contraceptives selected by clients post-counselling, as well as client and provider characteristics. Based on formative research and using Principal Component Analysis, we developed a 13-item measure of quality of FP counselling. We used adjusted regression models to assess the association between QFPC and contraceptive selected post-counselling.

RESULTS

The QFPC measure demonstrated good internal reliability (Cronbach alpha = 0.80) as well as criterion validity, as indicated by client reports of high QFPC being significantly more likely for clients with trained versus untrained counsellors. We found that each point increase in QFPC, including increasing quality of counselling, is associated with higher odds of clients selecting an intrauterine device (IUD) (aRR:1.03; 95% CI:1.01-1.05) and sterilization (aRR:1.06; 95% CI:1.03-1.08), compared to no method selected.

CONCLUSIONS

High-quality FP counselling is associated with clients subsequently selecting more effective contraceptives, including IUD and sterilization, in India. High-quality counselling is also more likely among FP-trained providers, highlighting the need for focused training and monitoring of quality care.

TRIAL REGISTRATION

CTRI/2015/09/006219. Registered 28 September 2015.

Client-provider interaction: understanding client experience with family planning service providers through the mystery client approach in India

The benefits of employing a rights-based approach in family planning (FP) programmes have made the client's rights to informed choices and quality care an essential part of any such programme. client-provider interaction is one of the critical components of the quality of care (QoC) framework of FP. While several studies have assessed QoC in FP services in India, very few have focused on the in-depth assessment of the interaction between the client and the provider during service delivery. The present study used the mystery client approach to assess the quality of interactions between clients and FP service providers in two of the most populous states of India: Bihar and Uttar Pradesh (UP). Findings highlighted that the providers spent very little time with the clients, gave them information on only one or two FP methods, and rarely talked about possible side-effects of the methods. Furthermore, the providers seemed hesitant to suggest any FP method other than condoms to newly married women. This study concluded that despite being a government priority, the quality of client-provider interaction in these two states was extremely poor.

Implementing social accountability for contraceptive services: lessons from Uganda

BACKGROUND

Growing evidence shows that social accountability contributes to improving health care services, with much promise for addressing women's barriers in contraceptive care. Yet little is known about how social accountability works in the often-complex context of sexual and reproductive health, particularly as sex and reproduction can be sensitive topics in the open and public formats typical of social accountability. This paper explores how social accountability operates in the highly gendered and complex context of contraceptive care.

METHODS

This exploratory research uses a case study approach to provide a more grounded understanding of how social accountability processes operate in the context of contraceptive information and services. We observed two social accountability projects that predominantly focused on contraceptive care in Uganda over a year. Five instruments were used to capture information from different source materials and multiple respondents. In total, one hundred and twenty-eight interviews were conducted and over 1000 pages of project documents were collected. Data were analyzed and compiled into four case studies that provide a thick description of how these two projects operated.

RESULTS

The case studies show the critical role of information, dialogue and negotiation in social accountability in the context of contraceptive care. Improved community and health system relationships, community empowerment, provider and health system responsiveness and enhanced availability and access to services were reported in both projects. There were also changes in how different actors related to themselves and to each other, and contraceptive care, a previously taboo topic, became a legitimate area for public dialogue.

CONCLUSION

The study found that while social accountability in the context of contraceptive services is indeed sensitive, it can be a powerful tool to dissolving resistance to family planning and facilitating a more productive discourse on the topic.

Design and pilot testing of a church-based intervention to address interpersonal and intrapersonal barriers to uptake of family planning in rural Tanzania: a qualitative implementation study

BACKGROUND

Use of family planning (FP) saves the lives of mothers and children, and contributes to better economic outcomes for households and empowerment for women. In Tanzania, the overall unmet need for FP is high. This study aimed: (1) to use focus group data to construct a theoretical framework to understand the multidimensional factors impacting the decision to use FP in rural Tanzania; (2) to design and pilot-test an educational seminar, informed by this framework, to promote uptake of FP; and (3) to assess acceptability and further refine the educational seminar based on focus group data collected 3 months after the education was provided.

METHODS

We performed a thematic analysis of 10 focus group discussions about social and religious aspects of FP from predominantly Protestant church attenders prior to any intervention, and afterwards from six groups of church leaders who had attended the educational seminar.

RESULTS

Key interpersonal influences included lack of support from husband/partner, family members, neighbours and church communities. Major intrapersonal factors impeding FP use were lack of medical knowledge and information, misconceptions, and perceived incompatibility of FP and Christian faith. Post-seminar, leaders reported renewed intrapersonal perspectives on FP and reported teaching these perspectives to community members.

CONCLUSIONS

Addressing intrapersonal barriers to FP use for leaders led them to subsequently address both intrapersonal and interpersonal barriers in their church communities. This occurred primarily by increasing knowledge and support for FP in men, family members, neighbours and church communities.

Improving access to contraception through integration of family planning services into a multidrug-resistant tuberculosis treatment programme

OBJECTIVES

Multidrug-resistant tuberculosis (MDR-TB) is a global public health priority. The advent of the World Health Organisation's Short Course regimen for MDR-TB, which halves treatment duration, has transformed outcomes and treatment acceptability for affected patients. Bedaquiline, a cornerstone of the Short Course regimen, has unknown teratogenicity and the WHO therefore recommends reliable contraception for all female MDR-TB patients in order to secure eligibility for bedaquiline. We were concerned that low contraceptive uptake among female patients in our rural South African MDR-TB treatment programme could jeopardise their access to bedaquiline. We therefore conducted a service delivery improvement project that aimed to audit contraceptive use in female MDR-TB patients, integrate family planning services into MDR-TB care, and increase the proportion of female patients eligible for bedaquiline therapy.

METHODS

Contraceptive use and pregnancy rates were audited in all female patients aged 13-50 years initiated on our MDR-TB treatment programme in 2016. We then implemented an intervention consisting of procurement of depot-medroxyprogesterone acetate (DMPA) for the MDR-TB unit and training of specialist MDR-TB nurses in administration of DMPA. The audit cycle was repeated for all female patients aged 13-50 years initiated on the programme in January-October 2017 (post-intervention).

RESULTS

The proportion of women on injectable contraceptives by the time of MDR-TB treatment initiation increased significantly in the post-intervention cohort (77.4% vs 23.9%, p<0.0001).

CONCLUSION

By integrating contraceptive services into our MDR-TB programme we significantly increased contraceptive uptake, protecting women from the obstetric risks associated with pregnancy during MDR-TB treatment and maximising their eligibility for bedaquiline therapy.

Expanding choice through online contraception: a theory of change to inform service development and evaluation

BACKGROUND

This study presents the theory of change underpinning an intervention to provide online contraceptive care in an inner London area with high rates of unplanned pregnancy. It aims to suggest attributes of an effective service and to identify key questions for its evaluation.

METHODS

Thematic analysis of an online sexual and reproductive health programme funding application and 21 semi-structured interviews with a purposive sample of stakeholders selected to provide expertise in contraception and online health.

RESULTS

A theory of change model summarised the positive processes of change which could be initiated through increased access to contraceptive supplies, online information and remote interaction and support. Stakeholders predicted that perceptions of convenience and anonymity of online access would vary across the target population. They stressed the importance of trusting service-users' capabilities for autonomous contraceptive decision-making, but expressed concerns that online access could be detrimental for those requiring more complex care. Concerns were alleviated by the prospect of responsive support through text messaging and phone calls, and when the online service was positioned as part of a broader system of provision including physical services.

CONCLUSIONS

This study has revealed priority areas for the ongoing development of an online contraception service and pertinent evaluation questions. Evaluative research should test assumptions within the theory of change model, exploring the characteristics and circumstances of those preferring online access over existing services and the value of convenience, anonymity, autonomous access and responsive support in executing effective contraceptive choices within a new landscape of contraceptive delivery.

Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal

Introduction:

Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities.

Methods:

A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23.

Results:

Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method.

Conclusions:

The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Assessing research impact: A framework and an evaluation of the Society of Family Planning Research Fund's grantmaking (2007-2017)

The Society of Family Planning Research Fund (SFPRF) provides grants for research on abortion and contraception. In 2017, SFPRF conducted a retrospective evaluation of its investment in family planning research. Using a developmental evaluation approach, we created a framework for assessing research impact in family planning and applied it to an analysis of our grantmaking between 2007 and 2017. Our framework consists of 30 indicators of research impact, which span nine impact categories from building researchers' capacity to influencing individuals, communities, and systems. Through application of this framework to our grantmaking, we learned that our grantmaking has helped build the research capacity of emerging and established family planning scholars and advance the field of family planning by supporting the creation of a robust scholarly evidence base. At the same time, we identified less evidence of impact on policy and practice. The results of this analysis directed SFPRF to move towards more focused funding opportunities, including longer-term and larger investments, and to prioritize partnerships between researchers and knowledge brokers.

Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix

When designing a family planning (FP) strategy, decision‐makers can choose from a wide range of interventions designed to expand access to and develop demand for FP. However, not all interventions will have the same impact on increasing modern contraceptive prevalence (mCP). Understanding the existing evidence is critical to planning successful and cost‐effective programs. The Impact Matrix is the first comprehensive summary of the impact of a full range of FP interventions on increasing mCP using a single comparable metric. It was developed through an extensive literature review with input from the wider FP community, and includes 138 impact factors highlighting the range of effectiveness observed across categories and subcategories of FP interventions. The Impact Matrix is central to the FP Goals model, used to project scenarios of mCP growth that help decision‐makers set realistic goals and prioritize investments. Development of the Impact Matrix, evidence gaps identified, and the contribution to FP Goals are discussed.

Competency assessment of the medical interns and nurses and documenting prevailing practices to provide family planning services in teaching hospitals in three states of India

Objectives

The objectives of the study were to assess the knowledge and skills of medical interns and nurses regarding family planning (FP) services, and document the prevailing FP practices in the teaching hospitals in India.

Study design

A cross-sectional study was conducted in three states (Delhi, Rajasthan, and Maharashtra) of India, among randomly selected 163 participants, including medical interns (n = 81) and in-service nurses (n = 82), during 2017. The semi-structured, pre-tested interview schedule, was used to assess the knowledge and status of training received; and objective structured clinical examination (OSCE) based checklist was used to evaluate the skills.

Results

About 60% of the interns and 48% of the nurses knew more than five contraceptives that could be offered to the clients. About 22% (11.1% interns and 33.3% nurses) respondents believed that contraceptives should not be given to a married woman coming alone, and 31.9% (17.3% interns and 46.3% nurses) respondents reported that it was illegal to provide contraceptives to unmarried people. Nearly 43.3% interns and 69.5% nurses refused to demonstrate intrauterine contraceptive device (IUCD) insertion in the dummy uterus as per OSCE, and among those who did, 12.3% interns and 18.3% nurses had failed. About 63% interns and 63.4% of nurses had observed IUCD insertion, and 12.3% interns and 17.1% had performed IUCD insertion, during their training.

Conclusions

Knowledge and skills of interns and nurses regarding FP services were inadequate. The medical training during graduation or internship, and during the job, was found to be inadequate to provide quality FP services as per guidelines of nursing/medical council of India and Government of India on FP.

Innovative approaches to reduce unintended pregnancy and improve access to contraception among women who use opioids

Dramatic increases in the rate of opioid use disorder (OUD) during pregnancy have been paralleled by substantial increases in the number of neonates diagnosed with neonatal abstinence syndrome (NAS). Women with OUD have reliably reported high rates of unintended pregnancy and a number of studies also indicate they desire easier access to contraception. Recent statements from the Centers for Disease Control and Prevention and the American Academy of Pediatrics/American College of Obstetricians and Gynecologists have drawn increased attention to efforts to prevent unintended pregnancy and improve access to contraception among women with OUD. We briefly review a number of innovative clinical approaches in these areas, including efforts to integrate family planning services into substance use disorder (SUD) treatment and other settings that serve people with OUD and interventions that aim to make family planning a higher priority among women with OUD. Results suggest many of these approaches have led to increases in contraceptive use and may aid in efforts to reduce unintended pregnancy and improve access to contraception among women with OUD now and in the future.

A systematic review and meta-analysis of postpartum contraceptive use among women in low- and middle-income countries

BACKGROUND

Short birth intervals increase risk for adverse maternal and infant outcomes including preterm birth, low birth weight (LBW), and infant mortality. Although postpartum family planning (PPFP) is an increasingly high priority for many countries, uptake and need for PPFP varies in low- and middle-income countries (LMIC). We performed a systematic review and meta-analysis to characterize postpartum contraceptive use, and predictors and barriers to use, among postpartum women in LMIC.

METHODS

PubMed, EMBASE, CINAHL, PsycINFO, Scopus, Web of Science, and Global Health databases were searched for articles and abstracts published between January 1997 and May 2018. Studies with data on contraceptive uptake through 12 months postpartum in low- and middle-income countries were included. We used random-effects models to compute pooled estimates and confidence intervals of modern contraceptive prevalence rates (mCPR), fertility intentions (birth spacing and birth limiting), and unmet need for contraception in the postpartum period.

RESULTS

Among 669 studies identified, 90 were selected for full-text review, and 35 met inclusion criteria. The majority of studies were from East Africa, West Africa, and South Asia/South East Asia. The overall pooled mCPR during the postpartum period across all regions was 41.2% (95% CI: 15.7-69.1%), with lower pooled mCPR in West Africa (36.3%; 95% CI: 27.0-45.5%). The pooled prevalence of unmet need was 48.5% (95% CI: 19.1-78.0%) across all regions, and highest in South Asia/South East Asia (59.4, 95% CI: 53.4-65.4%). Perceptions of low pregnancy risk due to breastfeeding and postpartum amenorrhea were commonly associated with lack of contraceptive use and use of male condoms, withdrawal, and abstinence. Women who were not using contraception were also less likely to utilize maternal and child health (MCH) services and reside in urban settings, and be more likely to have a fear of method side effects and receive inadequate FP counseling. In contrast, women who received FP counseling in antenatal and/or postnatal care were more likely to use PPFP.

CONCLUSIONS

PPFP use is low and unmet need for contraception following pregnancy in LMIC is high. Tailored counseling approaches may help overcome misconceptions and meet heterogeneous needs for PPFP.

The effects of community-based distribution of family planning services on contraceptive use: The case of a national scale-up in Malawi

RATIONALE

Although many sub-Saharan African countries have scaled-up pilot projects of community-based distribution (CBD) of family planning services, the effects of the scaled-up CBDs on contraceptive use remain unclear.

OBJECTIVE

We leveraged a national scale-up of Malawi's Learning and Innovation Population and Family Planning pilot to evaluate the effects of a scale-up of CBDs on contraceptive use. We also investigated whether education and income, two important determinants of contraceptive use behaviors, moderate the effects of the scaled-up CBDs.

METHOD

We used the 2000/2004 and 2010/2016 Malawi Demographic and Health Surveys (N = 57,978) and difference-in-differences analyses to estimate the effects of the 2005 national scale-up of CBDs on modern contraceptive use. We used rural and urban communities as the intervention and comparison groups because the national CBDs were implemented only in rural communities. Contraceptive use is defined as the current use of any modern contraceptive method (e.g., pills) and was modelled using multilevel logistic regression.

RESULTS

Prior to the implementation of the national scale CBDs (2000/2004), the probability of using contraceptives was 21.5% in rural communities and 26.3% in urban communities. After the scale-up (2010/2016), the probability of using contraceptives increased in both rural and urban communities but was greater in rural communities (44.9% vs. 42.9%). The effect attributable to the national scale CBDs was 6.8 percentage points (95% CI [3.3, 9.7]). The effects of the national CBDs were greater among uneducated and low-income women.

CONCLUSIONS

These findings suggest that national CBDs increase overall contraceptive use, particularly in rural communities, and that poor and uneducated women benefit more from family planning interventions that reduce communication and financial barriers.

Health Care Provider Attitudes Toward Safety of Selected Hormonal Contraceptives in Breastfeeding Women

OBJECTIVES

Little is known about provider attitudes regarding safety of selected hormonal contraceptives among breastfeeding women.

METHODS

Using a nationwide survey, associations were analyzed between provider characteristics and perception of safety of combined oral contraceptives (COCs) in breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors and depot medroxyprogesterone acetate (DMPA) in breastfeeding women < 1 month postpartum and ≥ 1 month postpartum.

RESULTS

Approximately 68% of public-sector providers considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among non-physicians versus physicians (adjusted odds ratios [aOR] range 0.34-0.51) and those with a focus on adolescent health/pediatrics versus reproductive health (aOR 0.68, 95% confidence interval [CI] 0.47-0.99). Most public-sector providers considered DMPA safe for breastfeeding women during any time postpartum, with lower odds among non-physicians versus physicians (aOR range 0.20-0.54) and those with primary clinical focus other than reproductive health (aOR range 0.26-0.65). The majority of office-based physicians considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among those who did not use, versus those who used, CDC's contraceptive guidance (aOR 0.40, 95% CI 0.21-0.77). Most office-based physicians also considered DMPA safe for breastfeeding women during any time postpartum.

CONCLUSIONS FOR PRACTICE

A high proportion of providers considered use of selected hormonal contraceptives safe for breastfeeding women, consistent with evidence-based guidelines. However, certain provider groups might benefit from education regarding the safety of these methods for breastfeeding women.

Perceptions of Contraception and Patterns of Switching Contraceptive Methods Among Family-planning Acceptors in West Nusa Tenggara, Indonesia

OBJECTIVES

The perceptions of family-planning (FP) acceptors regarding contraception influence the reasons for which they choose to switch their method of contraception. The objective of this study was to analyze the perceptions of contraception and rationales for switching contraceptive methods among female FP acceptors in West Nusa Tenggara, Indonesia.

METHODS

This study involved the analysis of secondary data from the Improve Contraceptive Method Mix study, which was conducted in 2013 by the Center for Health Research, University of Indonesia. The design of the study was cross-sectional. We performed 3 stages of sampling using the cluster technique and selected 4819 women who were FP acceptors in West Nusa Tenggara Province, Indonesia as the subjects of this study. The data were analyzed using multiple logistic regression.

RESULTS

The predominant pattern of switching contraceptive methods was switching from one non-long-term method of contraception to another. Only 31.0% of the acceptors reported a rational pattern of switching contraceptive methods given their age, number of children, and FP motivations. Perceptions of the side effects of contraceptive methods, the ease of contraceptive use, and the cost of the contraceptives were significantly associated (at the level of α=0.05) with rational patterns of switching contraceptive methods.

CONCLUSIONS

Perceptions among FP-accepting women were found to play an important role in their patterns of switching contraceptive methods. Hence, fostering a better understanding of contraception through high-quality counseling is needed to improve perceptions and thereby to encourage rational, effective, and efficient contraceptive use.

Fecundity and human birth seasonality in Sweden: a register-based study

BACKGROUND

It is well-established that couples' fecundities vary widely. Each couple has a relatively constant monthly probability of conceiving, which can vary from zero to quite high. This underlying probability is usually expressed as the time (number of menstrual cycles) the couple requires to conceive. Couples with high fecundity will, on average, need fewer cycles than couples with low fecundity. It is also well-documented that almost all human populations exhibit seasonal variation in births. Most European countries show seasonal variation that usually peak in the spring and are the lowest during the last quarter of the year. The increasingly strong pattern of depressed birth rates in November and December is likely explained by the December-January cut-off threshold for Swedish pupils' school entry and their parents increasing awareness of the negative effects on school outcomes for children who are juniors in the school-entry cohort they belong to. To actively plan births for a specific time of the year, couples need to have some knowledge of the time required for them to conceive.

METHODS

We use the duration between marriage of childless couples and first birth as a proxy measure of couples' fecundity. Based on this time-to-pregnancy measure we study to what extent couples' capacity to conceive affects the seasonality of their second births. We hypothesize that in a society with highly controlled fertility and a strong norm of having at least two children, sub-fertile couples will on average show less seasonal variation in second births. Sub-fertile couples, requiring more time to conceive the first time, will be less likely to try to target a desired birth month for their second child because doing so could jeopardize fulfilling their desired family size. We apply multinomial logistic regressions on 81,998 Swedish couples who married while being childless and subsequently gave birth to at least two children between 1990 and 2012, to investigate fecundity's role in seasonal variation in second births.

RESULTS

We found that seasonal variation in second births was strongly associated with couples' observed fecundity, measured as the duration between marriage formation and first birth. Our results support the hypothesis that sub-fertile couples, requiring more time to conceive the first time, show less seasonal variation in second births. The seasonal variations in second order births among couples with normal fecundity shows some similarities to traditional patterns as seen in agricultural and industrial societies of the past, with high numbers of births during the spring, and low numbers during the last quarter of the year. However, two important differences are notable. The characteristic Christmas peak in September has vanished, and the low birth rates in November and December come out much stronger than in the past.

CONCLUSIONS

The birth seasonality among couples with normal fecundity are what we would expect if couples actively plan their births according to the cut-off date for Swedish pupils' school entry. We argue that our findings support the notion that scheduled childbirth is a reality in contemporary sociality.

Effect of Family Planning Counseling After Delivery on Contraceptive Use at 24 Weeks Postpartum in Kinshasa, Democratic Republic of Congo

Introduction Unintended pregnancy during the postpartum period is common. The aim of this study was to describe contraceptive use among postpartum women and assess whether family planning counseling offered by health care providers during well-baby clinic visits increased use of modern contraceptive methods at 6 months following delivery. Methods Data comes from a cohort of women enrolled in a breastfeeding promotion trial in Kinshasa, Democratic Republic of Congo who reported being sexually active at 24-weeks post-partum. Modern contraceptive methods included intrauterine devices, injectables, implants, and contraception pills. Logistic regression models were used to estimate odd ratios (OR) and 95% confidence intervals (CI) for the impact of nurse counseling on use of modern birth control methods. Results Of 522 participants who reported being sexually active, 251 (48.0%) reported doing at least one thing to avoid pregnancy and were included in this analysis. Of these 251, 14.3% were using a modern contraceptive method, despite availability at the clinic. Discussion with a nurse about family planning was associated with increased odds of using modern birth control relative to other methods (OR 4.0, 95% CI 1.9, 8.6). Discussion Discussion of family planning with a nurse increased the odds of using a modern contraceptive among postpartum women. Integration of family planning counseling into postpartum services offers a potential avenue to increase modern contraceptive use among women with access.

Healthcare providers' perspectives on use of the national guideline for family planning services in Amhara Region, Ethiopia: a qualitative study

OBJECTIVE

To explore healthcare providers' views on barriers to and facilitators of use of the national family planning (FP) guideline for FP services in Amhara Region, Ethiopia.

DESIGN

Qualitative study.

SETTING

Nine health facilities including two hospitals, five health centres and two health posts in Amhara Region, Northwest Ethiopia.

PARTICIPANTS

Twenty-one healthcare providers working in the provision of FP services in Amhara Region.

PRIMARY AND SECONDARY OUTCOME MEASURES

Semistructured interviews were conducted to understand healthcare providers' views on barriers to and facilitators of the FP guideline use in the selected FP services.

RESULTS

While the healthcare providers' views point to a few facilitators that promote use of the guideline, more barriers were identified. The barriers included: lack of knowledge about the guideline's existence, purpose and quality, healthcare providers' personal religious beliefs, reliance on prior knowledge and tradition rather than protocols and guidelines, lack of availability or insufficient access to the guideline and inadequate training on how to use the guideline. Facilitators for the guideline use were ready access to the guideline, convenience and ease of implementation and incentives.

CONCLUSIONS

While development of the guideline is an important initiative by the Ethiopian government for improving quality of care in FP services, continued use of this resource by all healthcare providers requires planning to promote facilitating factors and address barriers to use of the FP guideline. Training that includes a discussion about healthcare providers' beliefs and traditional practices as well as other factors that reduce guideline use and increasing the sufficient number of guideline copies available at the local level, as well as translation of the guideline into local language are important to support provision of quality care in FP services.

Cost-Effectiveness of Scaling Up Modern Family Planning Interventions in Low- and Middle-Income Countries: An Economic Modeling Analysis in Indonesia and Uganda

OBJECTIVES

The aim was to estimate the long-term cost-effectiveness of improved family planning interventions to reduce the unmet need in low- and middle-income countries, with Indonesia and Uganda as reference cases.

METHODS

The analysis was performed using a Markov decision analytic model, where current situation and several scenarios to reduce the unmet need were incorporated as the comparative strategies. Country-specific evidence was synthesized from the demographic and health survey and published studies. The model simulated the sexual and reproductive health experience of women in the reproductive age range over a time horizon of women's reproductive years, from the healthcare payer perspective. Modeled outcomes included clinical events, costs and incremental cost-effectiveness ratios (ICERs) expressed as cost per disability-adjusted life year (DALY) averted. Deterministic and probabilistic sensitivity analyses were conducted to assess the impact of parameter uncertainty on modeled outcomes.

RESULTS

In the hypothetical cohort of 100,000 women, scenarios to reduce the unmet need for family planning would result in savings within a range of US$230,600-US$895,100 and US$564,400-US$1,865,900 in Indonesia and Uganda, respectively. The interventions would avert an estimated 1859-3780 and 3705-12,230 DALYs in Indonesia and Uganda, respectively. The results of our analysis indicate that scaling up family planning dominates the current situation in all scenarios in both countries, with lower costs and fewer DALYs. These results were robust in sensitivity analyses.

CONCLUSION

Scaling up family planning interventions could improve women's health outcomes substantially and be cost-effective or even cost saving across a range of scenarios compared to the current situation.

Women empowerment as an enabling factor of contraceptive use in sub-Saharan Africa: a multilevel analysis of cross-sectional surveys of 32 countries

BACKGROUND

Women's empowerment has a direct impact on maternal and child health care service utilization. Large scope measurement of contraceptive use in several dimensions is paramount, considering the nature of empowerment processes as it relates to improvements in maternal health status. However, multicountry and multilevel analysis of the measurement of women's empowerment indicators and their associations with contraceptive use is vital to make a substantial intervention in the Sub-Saharan Africa context. Therefore, we investigated the impact of women's empowerment on contraceptive use among women in sub-Saharan Africa countries.

METHODS

Secondary data involving 474,622 women of reproductive age (15-49 years) from the current Demographic and Health Survey (DHS) in 32 Sub-Saharan Africa region was used in this study. Contraceptive use was the primary outcome variable. Multilevel analysis was conducted to examine the impact of women's empowerment on contraceptive use. Percentages were conducted in univariate analysis. Furthermore, multilevel logistic regression models were used to analyze the association between individual, compositional and contextual factors of contraceptive use.

RESULTS

Results showed large disparities in the number of women who reportedly ever use contraceptive methods; this range from as low as 6.7% in Chad and as much as 72% in Namibia. More than one-third of the respondents had no formal education and more than half were active labor force. Contraceptive use was significantly more common among respondents from the richest households (28.5% versus 18.9%). Various components of women's empowerment were positively significantly associated with contraceptive use after adjusting for demographic and socioeconomic factors. There was a significant variation in the odds of contraceptive use across the 32 countries (σ2= 1.12, 95% CrI 0.67 to 1.87) and across the neighbourhoods (σ2= 0.95, 95% CrI 0.92 to 0.98).

CONCLUSIONS

Our findings suggest that an increase in contraceptive use and by better extension maternal health care services utilization can be achieved by enhancing women's empowerment. Also, an increase in decision-making autonomy by women, their participation in labour force, reduction in abuse and violence and improved knowledge level are all key issues to be considered. Health-related policies should address inequalities in women's empowerment, education and economic status which would yield benefits to individuals, families, and societies in general.

Program assessment of efforts to improve the quality of postpartum counselling in health centers in Morogoro region, Tanzania

BACKGROUND

The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania.

METHODS

Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10).

RESULTS

While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment.

CONCLUSIONS

Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged.

Revising the FP Quality of Care Framework in the Context of Rights-based Family Planning

Nearly three decades ago, Bruce articulated a client-centered quality of care (QoC) framework for family planning services. The term quality has since then been used in many rights-based frameworks for health, reproductive health, and family planning. This commentary compares the concept of quality used in many of these frameworks to reconcile the elements of the FP QoC framework with the use of quality in various rights frameworks. We propose five modifications to the original FP QoC framework to better align it with the treatment of quality in the rights-based approaches and the way quality in family planning has been applied in practice.

The effects of health facility access and quality on family planning decisions in urban Senegal

Research in developing countries is rarely focused on examining how supply side factors affect family planning decisions due to a lack of facility-level data. When these data exist, analyses tend to focus on rural environments. In this paper, we study the effects that health facility access and quality have on contraceptive use and desired number of children for women in urban Senegal. Unlike related studies focusing on rural environments, we find no evidence that greater access to health facilities and pharmacies increases contraceptive use among urban women. However, we do find that contraceptive use among urban women is higher with greater facility quality. For example, we find that increasing the proportion of pharmacies employing multiple pharmacists from 0% to 50% would increase contraceptive use by 6.0 percentage points, and increasing the proportion of facilities with family planning guidelines/protocols from 50% to 100% would increase use by 2.1 percentage points.

SMFM Special Report: Putting the "M" back in MFM: Addressing education about disparities in maternal outcomes and care

At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them.

Review of quality assessment tools for family planning programmes in low- and middle-income countries

Measuring and tracking the quality of healthcare is a critical part of improving service delivery, clinic efficiency and health outcomes. However, no standardized or widely accepted tool exists to assess the quality of clinic-based family planning services in low- and middle-income countries. The objective of this literature review was to identify widely used public domain quality assessment tools with existing or potential application in clinic-based family planning programmes. Using PubMed, PopLine, Google Scholar and Google, key terms such as ‘quality assessment tool’, ‘quality assessment method’, ‘quality measurement’, ‘LMIC’, ‘developing country’, ‘family planning’ and ‘reproductive health’ were searched for articles, identifying 20 relevant tools. Tools were assessed to determine the type of quality components assessed, divided into structure and process components, level of application (national or facility), health service domain that can be assessed by the tool, cost and current use of the tool. Tools were also assessed for shortcomings based on application in a low- and middle-income clinic-based family planning programme, including personnel required, re-assessment frequency, assessment of structure, process and outcome quality, comparability of data over time and across facilities and ability to benchmark clinic results to a national benchmark. No tools met all criteria, indicating a critical gap in quality assessment for low- and middle-income family planning programmes. To achieve Universal Health Coverage, agreed on in the Sustainable Development Goals and to improve system-wide healthcare quality, we must develop and widely adopt a standardized quality assessment tool.

Estimates of Side Effects Counseling in Family Planning Using Three Data Sources: Implications for Monitoring and Survey Design

With growing attention to monitoring and improving quality of care, it is critical to have evidence-based recommendations to measure quality of care indicators and guidelines to interpret estimates from different data sources. This study facilitates methodological discussion regarding measurement of counseling for side effects in family planning, a critical component of quality. The study assesses and compares estimates of side effects counseling based on three data sources. Data came from nationally representative facility and household surveys, Service Provision Assessments, and Demographic and Health Surveys in four countries. The level of side effects counseling was unacceptably low and varied systematically by data source. Compared to observation data in the facility survey, exit interview data from the survey overestimated the level substantially, and its reporting had poor predictive value. Estimates from household surveys were comparable with the observation-based estimates applying the minimum definition of counseling. In monitoring quality of care, data sources should be carefully reviewed, and estimates may need to be adjusted if the sources are inconsistent.

Side-Effects and Social Norms Influencing Family Planning Use in Nepal

Background Effective family planning (FP) programs promote modern contraceptives and help individuals achieve their reproductive goals. Despite Nepal's relatively high contraceptive prevalence rate (50%), 27% of married women have an unmet need for FP, and almost half of Nepalese women give birth by the age of 20. This formative study explored the factors that influence the use of contraceptives in Nepal. Objective To provide information about barriers to family planning use, general fertility awareness, and barriers to family planning use among difficult to reach groups communities. Method This qualitative study was implemented in five districts in Nepal. A total of 36 focus group discussions, 18 participatory group discussions, and 144 in-depth interviews were conducted. Participants included young married women, men and FP service providers in eight village development committees and two municipalities. The interviews were digitally recorded, transcribed in Nepali and then translated into English. Data was organized using Atlas Ti 7 and coded using a thematic analysis. Result Four key themes emerged from the analyses: 1) limited knowledge on fertility awareness and family planning methods, 2) religious-cultural factors including social norms impediments contraceptives use, 3) fear of side-effects, myths and misconceptions about modern contraceptives, and 4) structural barriers such as limited family planning services, and lack of same gender providers make it difficult for many women to access modern contraceptives services. Conclusion Continuing Nepal's recent gains in contraceptives prevalence rate will require strong educational interventions addressing fertility awareness, social norms around son preference, dispelling fear of side-effects while increasing the family planning method-mix. Health service providers should continue counseling clients on the management of potential side-effects and ensure accurate information about modern contraceptives.

Quality of care in family planning services in Senegal and their outcomes

BACKGROUND

High quality of care in family planning (FP) services has been found to be associated with increased and continued use of contraceptive methods. The interpersonal skills and technical competence of the provider is one of the main components of quality of care. To study the process component of quality of care, the distribution of the FP counseling topics was examined by client, provider and facility characteristics. To assess the outcomes of quality of care, client satisfaction and their knowledge of their method's protection from STIs were used. This study examined the factors associated with these outcomes with a focus on provider counseling and training.

METHODS

Data from the 2012-2013 Senegal Service Provision Assessment survey was used for the analysis. The survey included a representative sample of the health facilities in Senegal and collects data by observing the clients' FP visits and conducting exit interviews. The main outcomes of interest were provider's counseling in FP, client's satisfaction with FP services and client's knowledge of their method's protection from STIs. Several covariates were used in the analysis which represent client, provider and facility characteristics.

RESULTS

The level of counseling was inadequate-- very low proportions of providers that performed different types of counseling. Counseling was more likely to be provided to new than returning clients. Approximately 84% of the clients were very satisfied with services but only 58% had correct knowledge of their method's protection from STIs. Clients were significantly less likely to be very satisfied when their providers counseled on side effects and when to return, and counseling provided on method's protection from STIs did not significantly improve knowledge in this area. Clients seen by a provider with FP training had almost twice the odds of having correct knowledge about their method's protection from STIs compared with clients seen by a provider with no recent training.

CONCLUSIONS

The percentage of providers offering FP counseling to their clients was relatively low and was ineffective on the client-focused outcomes. Interventions may be required for more effective counseling methods that are client-centered as well as providing more FP training to providers.

Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review

Evidence on the feasibility, effectiveness, and cost‐effectiveness of integrating family planning (FP) and HIV services has grown significantly since the 2004 Glion Call to Action. This systematic review adds to the knowledge base by characterizing the range of models used to integrate FP into HIV care and treatment, and synthesizing the evidence on integration outcomes among women living with HIV. Fourteen studies met our inclusion criteria, eight of which were published after the last systematic review on the topic in 2013. Overall, integration was associated with higher modern method contraceptive prevalence and knowledge, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Evidence for change in unmet need for FP was limited, although two of the three evaluations that measured unmet need suggested possible improvements associated with integrated services. However, improving access to FP services through integration was not always sufficient to increase the use of more effective (noncondom) modern methods among women who wanted to prevent pregnancy. Integration efforts, particularly in contexts where contraceptive use is low, must address community‐wide and HIV‐specific barriers to using effective FP methods alongside improving access to information, commodities, and services within routine HIV care.

Family Planning American Style Redux: Unintended Pregnancy Improves, Barriers Remain

This article discusses barriers to reducing unintended pregnancy. Numerous factors may explain the high rate of unintended pregnancy in the United States, including inadequate sex education, confusing media messages about sex, cultural attitudes about sex and young parenting, conflation of contraception with abortion, inadequate health care access, burdensome contraceptive dispensing practices, and hospital merger limitations on care. Successful and promising approaches to expanding access to reproductive health care and reducing unintended pregnancy are discussed.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Outcomes of intrauterine device insertion training for doctors working in primary care

BACKGROUND

Intrauterine devices (IUDs) are underused in Australia despite being one of the most effective, reversible methods of contraception.

OBJECTIVE

The objective of this article is to report on the outcomes of a competency-based IUD training program by Family Planning NSW for general practitioners (GPs).

METHODS

Pre-training and post-training questionnaires were used for a 12-month cohort study of GPs who undertook IUD insertion training.

RESULTS

Twenty-two GPs (92%) completed the follow-up questionnaire; 19 participants reported attempting a total of 238 IUD insertions, 212 (89%) of which were successful. Few complications were reported. Most participants cited inadequate remuneration, time constraints and lack of appropriate patients as barriers to performing IUD insertion. Nearly all (96%) were confident with IUD insertion in multiparous women, but only 46% felt confident inserting in nulliparous women. There was evidence of a reduction in referrals to external IUD inserters following training.

DISCUSSION

Training enabled GPs to insert IUDs in their practices, but more than two-thirds (68%) fitted fewer than 12 devices during follow-up. A number of barriers to IUD insertion in general practice can be addressed to improve community access.

Strengthening Postabortion Family Planning Services in Ethiopia: Expanding Contraceptive Choice and Improving Access to Long-Acting Reversible Contraception

Where unmet need for the safest, most effective, and long-acting reversible contraceptives (LARCs) is very high, the health system and partners need to implement problem-solving, locally feasible, and comprehensive family planning delivery strategies. Because young and unmarried women are most at risk for unintended pregnancy and repeat abortion due to poor access to contraceptive services, postabortion family planning (PAFP) is a key component in such strategies. In Southern Nations, Nationalities, and People's Region, Ethiopia, Ipas implemented health system strengthening efforts from fiscal year (FY) 2010 (July 2009 to June 2010) to FY 2014 (July 2013 to June 2014) to improve the quality of PAFP services and expand method choice in 101 public facilities. The intervention significantly improved PAFP uptake at the project sites. Specifically, the proportion of abortion clients receiving LARCs progressively improved during the intervention period. The proportion of abortion clients who left the facilities with a contraceptive method increased from 58% in FY 2010 to 83% in FY 2014. The share of method mix for LARCs rose from 2% in FY 2010 to 55% in FY 2014, while the share for condoms, injectables, and oral contraceptives declined from 98% to 45%. Implant use rose from 2% in FY 2010 to 43% in FY 2014, while the use of intrauterine devices increased from 0.1% in FY 2010 to 12% in FY 2014. A larger proportion of PAFP users received LARCs at health centers, where midwives and nurses are the primary providers, than at hospitals (59% versus 37%, respectively). A broader method mix can satisfy clients with a variety of needs, a key factor for higher uptake of more effective methods and program success. Further evidence-based interventions need to be implemented to improve the quality of PAFP in a feasible and replicable strategy that addresses unmet need for modern contraceptive methods.

Comparison of family-planning service quality reported by adolescents and young adult women in Mexico

Objective

Associations between age and patient-reported quality of family planning services were examined among young women in Mexico.

Methods

A repeated cross-sectional analysis of survey data collected in 2006, 2009, and 2014 was performed. Data from women aged 15–29 years who had not undergone sterilization and were currently using a modern contraceptive method were included. The primary outcome was high-quality care, defined as positive responses to all five quality items regarding contraceptive services included in the survey. Multivariable logistic regression and marginal probabilities were used to compare adolescents and women aged 20–29 years. The responses of respondents using different contraceptive methods were compared.

Results

Data were included from 15 835 individuals. The multivariable analysis demonstrated lower odds of reporting high-quality care among women aged 15–19 years (odds ratio 0.73; 95% confidence interval 0.60–0.88) and 20–24 years (odds ratio 0.85; 95% confidence interval 0.75–0.96) compared with women aged 25–29 years. Adolescents using hormonal and long-acting reversible contraception had significantly lower odds of reporting high-quality care compared with women aged 25–29.

Conclusions

Adolescents in Mexico reported a lower quality of family planning services compared with young adult women. Continued research and policies are needed to improve the quality of contraceptive services.

Update: Providing Quality Family Planning Services - Recommendations from CDC and the U.S. Office of Population Affairs, 2015

In 2014, CDC published Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP), which describes the scope of services that should be offered in a family planning visit, and how to provide those services (e.g., periodicity of screening, which persons are considered to be at risk, etc.). The sections in QFP include Contraceptive Services, Pregnancy Testing and Counseling, Clients Who Want to Become Pregnant, Basic Infertility Services, Preconception Health Services, Sexually Transmitted Disease Services, Related Preventive Health Services, and Screening Services for Which Evidence Does Not Support Screening.

Privacy and Confidentiality Practices In Adolescent Family Planning Care At Federally Qualified Health Centers

CONTEXT

The confidentiality of family planning services remains a high priority to adolescents, but barriers to implementing confidentiality and privacy practices exist in settings designed for teenagers who are medically underserved, including federally qualified health centers (FQHCs).

METHODS

A sample of 423 FQHCs surveyed in 2011 provided information on their use of five selected privacy and confidentiality practices, which were examined separately and combined into an index. Regression modeling was used to assess whether various state policies and organizational characteristics were associated with FQHCs' scores on the index. In-depth case studies of six FQHCs were conducted to provide additional contextual information.

RESULTS

Among FQHCs reporting on confidentiality, most reported providing written or verbal information regarding adolescents' rights to confidential care (81%) and limiting access to family planning and medical records to protect adolescents' confidentiality (84%). Far fewer reported maintaining separate medical records for family planning (10%), using a security block on electronic medical records to prevent disclosures (43%) or using separate contact information for communications regarding family planning services (50%). Index scores were higher among FQHCs that received Title X funding than among those that did not (coefficient, 0.70) and among FQHCs with the largest patient volumes than among those with the smallest caseloads (0.43). Case studies highlighted how a lack of guidelines and providers' confusion over relevant laws present a challenge in offering confidential care to adolescents.

CONCLUSIONS

The organizational practices used to ensure adolescent family planning confidentiality in FQHCs are varied across organizations.

Financing Maternal Health and Family Planning: Are We on the Right Track? Evidence from the Reproductive Health Subaccounts in Mexico, 2003-2012

OBJECTIVE

To analyze whether the changes observed in the level and distribution of resources for maternal health and family planning (MHFP) programs from 2003 to 2012 were consistent with the financial goals of the related policies.

MATERIALS AND METHODS

A longitudinal descriptive analysis of the Mexican Reproductive Health Subaccounts 2003-2012 was performed by financing scheme and health function. Financing schemes included social security, government schemes, household out-of-pocket (OOP) payments, and private insurance plans. Functions were preventive care, including family planning, antenatal and puerperium health services, normal and cesarean deliveries, and treatment of complications. Changes in the financial imbalance indicators covered by MHFP policy were tracked: (a) public and OOP expenditures as percentages of total MHFP spending; (b) public expenditure per woman of reproductive age (WoRA, 15-49 years) by financing scheme; (c) public expenditure on treating complications as a percentage of preventive care; and (d) public expenditure on WoRA at state level. Statistical analyses of trends and distributions were performed.

RESULTS

Public expenditure on government schemes grew by approximately 300%, and the financial imbalance between populations covered by social security and government schemes decreased. The financial burden on households declined, particularly among households without social security. Expenditure on preventive care grew by 16%, narrowing the financing gap between treatment of complications and preventive care. Finally, public expenditure per WoRA for government schemes nearly doubled at the state level, although considerable disparities persist.

CONCLUSIONS

Changes in the level and distribution of MHFP funding from 2003 to 2012 were consistent with the relevant policy goals. However, improving efficiency requires further analysis to ascertain the impact of investments on health outcomes. This, in turn, will require better financial data systems as a precondition for improving the monitoring and accountability functions in Mexico.

Systematic Review Evidence Methodology: Providing Quality Family Planning Services

From 2010 to 2014, CDC and the Office of Population Affairs at the USDHHS collaborated on the development of clinical recommendations for providing quality family planning services. A high priority was placed on the use of existing scientific evidence in developing the recommendations, in accordance with IOM guidelines for how to develop "trustworthy" clinical practice guidelines. Consequently, a series of systematic reviews were developed using a transparent and reproducible methodology aimed at ensuring that the clinical practice guidelines would be based on evidence collected in the most unbiased manner possible. This article describes the methodology used in conducting these systematic reviews, which occurred from mid-2011 through 2012.

Programs to Strengthen Parent-Adolescent Communication About Reproductive Health: A Systematic Review

CONTEXT

When caring for an adolescent client, providers of contraceptive services must consider whether and how to encourage parent/guardian-child communication about the adolescent's reproductive health. The objective of this systematic review was to summarize the evidence on the effectiveness of programs designed to increase parent-child communication about reproductive health. The review was used to inform national recommendations on quality family planning services. Data analysis occurred from mid-2011 through 2012.

EVIDENCE ACQUISITION

Several electronic bibliographic databases were used to identify relevant articles, including PubMed, CINAHL, PsycINFO, and Popline, published from January 1985 through February 2011.

EVIDENCE SYNTHESIS

Sixteen articles met the inclusion criteria: all studies examined the impact on at least one medium- or short-term outcome, and two studies assessed the impact on teen pregnancy. One study examined the impact of a program conducted in a clinic setting; the remainder examined the impact of programs in community settings. All studies showed a positive impact on at least one short-term outcome, and 12 of 16 studies showed an increase in parent-child communication about reproductive health. Four of seven studies found an impact on sexual risk behavior.

CONCLUSIONS

Most programs increased parent-child communication, and several resulted in reduced sexual risk behavior of adolescents. This suggests that delivering a clinic-based program that effectively helps parents/guardians talk to their adolescent child(ren) about reproductive health, or referring parents/guardians to an evidence-based program in the community, may be beneficial. However, further rigorous research on delivery of these programs in clinical settings is needed.