Funding for Abstinence-Only Education and Adolescent Pregnancy Prevention: Does State Ideology Affect Outcomes?

OBJECTIVES: To examine the relationship between adolescent pregnancy-prevention and sexuality and abstinence-only education funding and adolescent birthrates over time. Also, to determine whether state ideology plays a moderating role on adolescent reproductive health, that is, whether the funding has its intended effect at reducing the number of adolescent births in conservative but not in liberal states. METHODS: We modeled time-series data on federal abstinence-only and adolescent pregnancy-prevention and sexuality education block grants to US states and rates of adolescent births (1998-2016) and adjusted for state-level confounders using 2-way fixed-effects models. RESULTS: Federal abstinence-only funding had no effect on adolescent birthrates overall but displayed a perverse effect, increasing adolescent birthrates in conservative states. Adolescent pregnancy-prevention and sexuality education funding eclipsed this effect, reducing adolescent birthrates in those states. CONCLUSIONS: The millions of dollars spent on abstinence-only education has had no effect on adolescent birthrates, although conservative states, which experience the greatest burden of adolescent births, are the most responsive to changes in sexuality education-funding streams.

Making good on a call to expand method choice for young people - Turning rhetoric into reality for addressing Sustainable Development Goal Three.

BACKGROUND: Investments in the nearly two billion young people, aged 10-24 years, in the world today are necessary to meet global development commitments, specifically the Sustainable Development Goals and Ending Preventable Child and Maternal Deaths. More than 12 million married and unmarried adolescents (aged 15-19) will give birth in 2016. Complications of pregnancy and childbirth are the second leading cause of death among 15-19 year-old women and early childbearing can significantly curtail social and economic prospects for young women. Facilitating the ability of sexually active young people to choose and effectively use a satisfactory contraceptive method will ensure they can exercise their right to prevent, delay or space pregnancy. The Global Consensus Statement, "Expanding Contraceptive Choice for Adolescents and Youth to Include Long Acting and Reversible Contraception" provides evidence on the safety and effectiveness of LARCs for young people. Three inter-dependent actions linking advocacy and policy (advocating for policy and guideline revisions); supply (improving quality and accessibility of an expanded method choice) and an enabling environment (social norms and comprehensive reproductive health information) are suggested as vital to achieving full access and full choice for all sexually active young people. Identified approaches include national advocacy addressing policy guidelines and standard operating procedures that guide providers in the provision of age and developmentally appropriate contraceptive services; pre-service and in-service training for health care providers to be able to effectively communicate and counsel young people, including dispelling myths and misconceptions around LARCs; and partnering with young people to design appropriate, contextually-relevant, and effective strategies to increase their self-efficacy and, at the community level, address broader social norms to dispel stigma and discrimination. CONCLUSION: An immediate call to action for collaborative and coordinated global, regional and national efforts that enable full access and full choice for all young people is paramount to achieve their reproductive health intentions and the Sustainable Development Goal targets.

Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh.

In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladesh's approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.

Family planning in Guinea: a need for better public commitment.

OBJECTIVE: To describe the evolution of family planning (FP) in Guinea and to identify strengths, weaknesses, opportunities and threats of the current FP programme. METHODS: Descriptive study of the evolution of FP in Guinea between 1992 and 2010. First, national laws as well as health policies and strategic plans related to reproductive health and family planning were reviewed. Second, FP indicators were extracted from the Guinean Demographic and Health Surveys (1992, 1999 and 2005). Third, FP services, sources of supply and data on FP funding were analysed. RESULTS: Laws, policies and strategic plans in Guinea are supportive of FP programme and services. Public and private actors are not sufficiently coordinated. The general government expenditure on health has remained stable at 6-7% between 2005 and 2011 despite a doubling of total expenditures on health, and contraceptives are supplied by foreign aid. Modern contraceptive prevalence slightly increased from 1.5% in 1992 to 6.8% in 2005 among women aged 15-49. CONCLUSION: A stronger national engagement in favour of repositioning FP should result in improved government funding of the FP programme and the promotion of long-acting and permanent methods.

Need for integration of gender equity in family planning services.

The family planning programme of India has shown many significant changes since its inception five decades back. The programme has made the contraceptives easily accessible and affordable to the people. Devices with very low failure rate are provided free of cost to those who need it. Despite these significant improvements in service delivery related to family planning the programme cannot be said to achieve success at all levels. There are many issues with the family planning services available through the public health facilities in India. Failure to adopt the latest technology is one of these. But the most serious drawback of the programme is that it has never been able to bridge the gap between the two genders related to contraceptives. The programme gave emphasis to women-centric contraceptive and thus women were seen as their clients. The choice to adopt a contraceptive though is 'cafeteria approach' in family planning lexicon; it is the choice of the husband that is ultimately practiced. There is not enough dialogue between husband and wife and husband and health worker to discuss the use of one contraceptive over another. The male gender needs to be taken in confidence while promoting the family planning practice. The integration of gender equity is to be done carefully so as not to make dominant gender more powerful. Only when there is equity between genders while using family planning services the programme will achieve success.

Priority strategies for India's family planning programme.

Strategies to accelerate progress of India's family planning programme are discussed and the importance of improving the quality and reach of services to address unmet contraceptive need by providing method choice is emphasized. Although there is a growing demand for both limiting and spacing births, female sterilisation, is the dominant method in the national programme and use of spacing methods remains very limited. Fertility decline has been slower in the empowered action group (EAG) states which contribute about 40 per cent of population growth to the country and also depict gloomy statistics for other socio-development indicators. It is, therefore, important to intensify efforts to reduce both fertility and mortality in these states. arationale has been provided for implementing integrated programmes using a gender lens because the lack of women's autonomy in reproductive decision-making, compounded by poor male involvement in sexual and reproductive health matters, is a fundamental issue yet to be addressed. The need for collaboration between scientists developing contraceptive technologies and those implementing family planning services is underscored. If contraceptive technologies are developed with an understanding of the contexts in which they will be delivered and an appreciation of end-users' needs and perspectives, they are more likely to be accepted by service providers and used by clients.

Current challenges in contraception in adolescents and young women.

PURPOSE OF REVIEW: Although developing countries have made much progress in expanding the availability and use of family planning services, the need for effective contraception is large, and growing because the largest cohorts in human history are entering their reproductive years. Not only regarding developing countries but also in developed countries, where the usual contraceptive methods, such as the oral contraceptives, intrauterine devices (IUDs) and condoms, have been available for decades, there have been many new advances in contraceptive technology in the last several years. New formulations of oral contraceptives, extended and continuous use of oral contraceptives and long-acting reversible contraceptives (LARC) may have a wider role in contraception and their increased implementation could help to reduce unintended pregnancy. RECENT FINDINGS: Today's oral contraceptive regimens are safer and more tolerable, with equal or improved efficacy as compared to early formulations. Incremental decreases in the estrogen dosage have helped to alleviate some of the unwanted estrogenic side effects of combined hormonal contraceptives. Progestogens have also been controversial in connection with findings of increased venous thromboembolism risks but they have evolved over time, and, in general, newer generations of progestins have minimal side effects. Currently available 'LARC' methods, such as IUDs, the intrauterine system, injectable contraceptives and implants require administration less than once per cycle or month. They are more cost effective than the combined oral contraceptive pill even at 1 year of use. Increasing the access and availability of new formulations of oral contraceptives and LARC methods will reduce the number of unintended pregnancies. SUMMARY: Evidence-based guidelines about the safety of contraceptive methods among women with comorbid medical conditions can help guide providers in determining the best method of contraception for each woman, depending on whether they are in their adolescent, postpartum or perimenopause years. As most patients can safely use highly effective methods of contraception, health providers should promote their use in order to further efforts to reduce unintended pregnancy. This promotion should be done by enabling women to make an informed choice among all contraceptive options.

Why family planning matters.

Family planning is one of the principle tools of human development. Ensuring that all babies are wanted and planned reduces health care and social costs. Human numbers will increase to 11 billion by the end of this century, and human activities are the leading cause of environmental change that threaten our health and happiness. Therefore, the provision of highly effective contraceptive methods represents an important priority of primary medical care. Since women and men with complicated medical problems remain interested in sex, medical and surgical specialists need to understand how contraception and pregnancy will interact with the underlying condition. This paper discusses the interaction between population growth and the environment, and reviews modern methods of contraception.

What's Known and What's Next: Contraceptive Counseling and Support for Adolescents and Young Adult Women.

The low rates of actual contraceptive failure and high rates of contraceptive use among young women highlight that choice of contraceptive method and patterns of contraceptive use greatly influence unintended pregnancy risk. Promoting contraceptive use among adolescent and young adult women requires supportive health systems and health providers who understand this population's evolving developmental needs. It also requires an awareness of effective tools for counseling patients, while being mindful of the power dynamics operational during clinical encounters to avoid inadvertently coercive interpersonal dynamics. Missed opportunities to provide such patient-centered care can lead to unplanned pregnancies and suboptimal health and social consequences for young women. Unfortunately, health providers often lack the tools and resources to appropriately identify and meet individual young women's contraceptive needs. This article summarizes the evidence supporting contraceptive counseling strategies linked with contraceptive initiation among young women, and evidence-based approaches for supporting contraceptive adherence and continuation after method initiation. It also orients readers to the unique neurodevelopmental factors that influence the shared decision-making process during contraception counseling sessions with young women. New and emerging approaches for supporting contraceptive initiation, adherence, and continuation are reviewed.

Understanding drivers of family planning in rural northern India: An integrated mixed-methods approach.

BACKGROUND: Family planning is a key means to achieving many of the Sustainable Development Goals. Around the world, governments and partners have prioritized investments to increase access to and uptake of family planning methods. In Uttar Pradesh, India, the government and its partners have made significant efforts to increase awareness, supply, and access to modern contraceptives. Despite progress, uptake remains stubbornly low. This calls for systematic research into understanding the 'why'-why people are or aren't using modern methods, what drives their decisions, and who influences them. METHODS: We use a mixed-methods approach, analyzing three existing quantitative data sets to identify trends and geographic variation, gaps and contextual factors associated with family planning uptake and collecting new qualitative data through in-depth immersion interviews, journey mapping, and decision games to understand systemic and individual-level barriers to family planning use, household decision making patterns and community level barriers. RESULTS: We find that reasons for adoption of family planning are complex-while access and awareness are critical, they are not sufficient for increasing uptake of modern methods. Although awareness is necessary for uptake, we found a steep drop-off (59%) between high awareness of modern contraceptive methods and its intention to use, and an additional but smaller drop-off from intention to actual use (9%). While perceived access, age, education and other demographic variables partially predict modern contraceptive intention to use, the qualitative data shows that other behavioral drivers including household decision making dynamics, shame to obtain modern contraceptives, and high-risk perception around side-effects also contribute to low intention to use modern contraceptives. The data also reveals that strong norms and financial considerations by couples are the driving force behind the decision to use and when to use family planning methods. CONCLUSION: The finding stresses the need to shift focus towards building intention, in addition to ensuring access of trained staff, and commodities drugs and equipment, and building capacities of health care providers.

[Evolution and future of contraception]. / Evoluzione e futuro della contraccezione.

In order to meet the need for efficacious and safe contraception, contraceptives are in continuous evolution. Among oral contraceptives evolution has brought reduction of ethynylestradiol doses, up to change the estrogenic molecule to natural estradiol. In order to individualize contraception, numerous different progestin molecules have been developed and are being tested. Individualization has also brought at developing new schedules for contraceptive administration, and different routes of administration. Important developments have appeared on parenteral hormonal contraception, such as the intravaginal, subdermal, transdermal or injectable contraception. Intrauterine devices are being developed, becoming smaller, easier to insert, and sometimes capable to locally release progestins. New spermicides, that are capable to protect from sexually transmitted disease, are also being developed. Emergency contraception has evolved in a safer and more acceptable hormonal contraception. Recent introduction of molecules modulating progesterone receptors, seem to bring additional advantages by increasing the efficacy and extending the window of efficacy of emergency contraception.

Delivering family planning and preconception care to women with diabetes: Implementation challenges and promising strategies.

Diabetes is increasingly prevalent among women of reproductive age and during pregnancy. The American Diabetes Association, which has called for improvements in the patient-centeredness of care, recommends preconception counseling and care for women of reproductive age with diabetes. However, data suggests this care is not sufficiently delivered. In this article, we describe demographic shifts in the need for preconception care and outline several changes at the clinical encounter as well as the health system- and community-levels that can help improve the delivery of diabetes-specific preconception care.

Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries.

BACKGROUND: Increasing the coverage of key maternal, newborn, and child health interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. We have assessed equity and trends in coverage rates of a key set of interventions through a summary index, to provide overall insight into past performance and progress perspectives. METHODS: Data from household surveys from 54 countries in the Countdown to 2015 for Maternal, Newborn and Child Survival initiative during 1990-2006 were used to compute an aggregate coverage index based on four intervention areas: family planning, maternal and newborn care, immunisation, and treatment of sick children. The four areas were given equal weight in the computation of the index. Standard measures were applied to assess current levels and trends in the coverage gap measure by wealth quintile. FINDINGS: The overall size of the coverage gap ranged from less than 20% in Tajikistan and Peru to over 70% in Ethiopia and Chad, with a mean of 43% for the most recent surveys in the 54 countries. Large intracountry differences were noted, with a country mean coverage gap of 54% for the poorest quintiles of the population and 29% for the wealthiest. Differences between the poorest and the wealthiest were largest for the maternal and newborn health intervention area and smallest for immunisation. In 40 countries with more than one survey, the coverage gap had decreased by an average of 0.9 percentage points per year since the early 1990s. Declines greater than 2 percentage points per year were seen in only three countries after 1995: Cambodia, Mozambique, and Nepal. Country inequity patterns were remarkably persistant over time, with only gradual changes from top inequity (disproportionately smaller gap for the wealthiest) in countries with coverage gaps exceeding 40%, to linear patterns and bottom inequity (disproportionately greater gap for the poorest) in surveys with gaps below 40%. INTERPRETATION: Despite most Countdown countries having made gradual progress since 1990, coverage gaps for key interventions remain wide and, in most such countries, the pace of decline needs to be more than doubled to reach levels of coverage of these and other interventions needed in the context of MDG 4 and 5. In general, in-country patterns of inequality are consistant and change only gradually if at all, which has implications for the targeting of interventions.

The future of preconception care: a clinical perspective.

The concepts of preconception care (PCC) have been discussed for over 20 years and the standards for PCC have been recently promulgated by the clinical committee of the Centers for Disease Control and Prevention's Select Panel of Preconception Care. For PCC to be fully realized, however, changes must be made in clinical practice, public health supports, and health coverage. This article discusses 1) the clinical content and delivery of PCC, 2) barriers to why this care does not fit easily into the current clinical paradigm for providing medical care, and 3) how new information technologies within the concept of the medical home might be a promising new way to assist in the diffusion of these concepts.

Policy and finance for preconception care opportunities for today and the future.

This special supplement of Women's Health Issues offers 2 types of articles related to the policy and finance context for improving preconception health and health care. These articles discuss the impact of finance and policy on preconception health and health care, as well as the strategies that are being used to overcome the challenge of implementing preconception care with limited resources and inadequate health coverage for women. Invited papers from authors with expertise in health policy and finance issues describe how women's health and preconception care fit into the larger debates on health reform and how the paradigm for women's health must change. Other invited papers discuss opportunities and challenges for using programs such as Medicaid, Title X Family Planning, Title V Maternal and Child Health Services Block Grant, Healthy Start, and Community Health Centers in improving preconception health and health care. Contributed articles on health services research in this supplement characterize the types of change occurring across the country. This paper also presents a framework for understanding the role of policy and finance in the larger Centers for Disease Control and Prevention Preconception Health and Health Care Initiative.

Socio-Cultural Challenges of Family Planning Initiatives for Displaced Populations in Conflict Situations and Humanitarian Settings.

Provision of family planning services for refugee populations in conflict and humanitarian settings has been improving. Availability of services, however, does not translate into acceptability and uptake; understanding socio-cultural settings and barriers is critical to ensure utilization of services. Misconceptions and apprehensions surrounding family planning services are common. Populations may see limiting pregnancies as counterproductive in light of high child mortality or suspicious in the context of ethnic violence; larger family size has the perceived advantage of additional security for the community or ethnic group, assistance with family duties in a subsistence structure, and a social service investment for parents as they age; and there may be religious and moral objections to contraception. Any service planning and implementation must take into account community perceptions and address socio-cultural contextual subtleties. Ongoing community education via local initiatives from within the refugee community, region-wide structural strategies for service implementation and sustainability, and efforts to reconcile reproductive rights and family planning services within the religious and social context are crucial. (Disaster Med Public Health Preparedness. 2018;12:670-674).