Is addressing violence against women prioritised in health policies? Findings from a WHO policies database.

Violence against women (VAW) affects almost 1 in 3 women and can lead to short and long-term adverse health outcomes. The health sector is an important entry point to respond to VAW. Globally, countries have committed to eliminating VAW through the SDGs and WHO Member States have endorsed a Global Plan of Action on Violence, which asks countries to provide comprehensive health services to VAW survivors. To track progress and establish a baseline for the Global Plan of Action on Violence, WHO developed a VAW Policies Database to assess how countries are addressing VAW in health and multisectoral policies. This paper presents findings from 15 select indicators related to the existence of VAW-related policies and the inclusion of health services for survivors in policies in line with WHO recommendations. Results show that while 80% of countries have multisectoral VAW policies in place, only 34% have national health policies that include VAW response and/or prevention as a strategic priority, and 48% have clinical guidelines for the health sector response. Policies were analysed to identify inclusion of WHO-recommended VAW health services: 75% of countries' policies mention provision of first-line support; while 50% or fewer of countries mention clinical enquiry to identify intimate partner violence, post-rape care services, or mental health assessment, referral and treatment. The high-income countries group had the lowest proportion of countries that specified each of the above-mentioned health services in policies. Findings show that more efforts are needed to raise the awareness of ministries of health about the public health impact of VAW and the importance of including VAW in health policies. Where policies exist, many are not aligned with WHO-recommendations. Policy dialogues should be conducted with governments on how to better align their VAW policies with internationally-agreed, evidence-based standards, and to implement them through programmes and services.

Methodological reflections: developing the WHO database of violence against women policies.

This paper presents methodological reflections from the development of the World Health Organization (WHO) Violence against Women (VAW) Policies Database (hereinafter referred to as 'the Database') to inform future efforts to create similar public health policy databases for government accountability. Using the WHO Global Plan of Action on Violence accountability measures as a starting point, the Database was developed over a 2-year period in consultation with a reference group. A subset of indicators was piloted before finalization of a full list and the structure of the Database. Available VAW policies from 194 WHO Member States were reviewed by a team of consultants, who conducted content analysis and data entry. A 'Manual and User Guide' was developed to record decisions related to the processes for developing the Database. This guide was used to draw out key reflections in relation to policy indicators, inclusion criteria for policy documents, languages and analysis, quality assurance and sustainability. The process of developing the Database evolved iteratively in response to many factors, including the content of policies and the specificities of policy-making in each jurisdiction. Pragmatic decisions about the number of indicators and the types of policies to review were informed by pilot tests across a range of geographies. Standardization of analysis and data entry was ensured through the provision of in-depth guidance for researchers, and regular and open communication within the team was key to quality assurance. Online translation services enabled a review of policy documents in most languages. Documentation of the methodology ensured that others could replicate processes with fidelity in the future. Despite complexities, it is possible to develop a sound methodology for analysing the content of policy documents in a manner that yields findings that are useful in holding governments accountable for the commitments to address VAW and other public health issues in policy.

Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania.

INTRODUCTION: Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors. METHODS: A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted. RESULTS: Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.

Abortion knowledge and experiences among young women and men in Accra, Ghana.

Background : Despite the presence of legal abortion services in Ghana, unsafe abortion remains common, particularly among young women. Little is understood about what young people know about safe and legal abortion, and if and how they are utilizing it. Methods : To characterize abortion use and address gaps in safe access, from September-December 2013, we conducted a cross-sectional survey with 100 men and 250 women aged 18-24 in Accra, Ghana. Participants were asked about abortion experiences, including prior services, providers, methods, satisfaction, perceived support, and knowledge of laws. Descriptive statistics, Fisher's exact tests, and chi-square tests were performed. Results : Among surveyed youth, most (87% of women, 64% of men) thought abortion was illegal or did not know the law. In total, 30% of women and 14% of men ever had an abortion and partner who had an abortion, respectively. Among women's most recent abortions, medication abortion (61%), surgical methods (26%), and unsafe methods categorized "least safe" (14%) were the initial or only methods used. Most women who accessed medication abortion initially or as their only method saw a pharmacist (40%) or no one (33%). Nearly one-quarter of women (n=16, 24%) who initially took tablets used more than one method. Conclusions : Despite experiences with abortion, most young people in this study were unaware of its legality and unsafe abortions occurred. More needs to be done to ensure young people understand the law and have access to safe methods, and that pharmacists are trained to provide appropriate doses and formulations of medication abortion.

Experiences With the Levonorgestrel Intrauterine System Among Clients, Providers, and Key Opinion Leaders: A Mixed-Methods Study in Nigeria.

BACKGROUND: The levonorgestrel intrauterine system (LNG IUS) is one of the most effective contraceptive methods, and it has noncontraceptive health benefits, including treatment for women with heavy menstrual bleeding. In 2016, Marie Stopes International Organisation Nigeria (MSION) expanded LNG IUS provision through training and support to 9 mobile outreach teams, 105 social franchise clinics, and 20 public-sector providers in 17 states. Information about the LNG IUS was added to awareness-raising materials, and community mobilizers provided information on the LNG IUS alongside other voluntary family planning methods. METHODS: In 2016, Marie Stopes International, MSION, and FHI 360 examined clients' and providers' experiences with the LNG IUS to assess the potential for further scale-up of the method as part of a comprehensive approach to family planning in Nigeria. A mixed-methods approach was used including analysis of routine service data, supplemental data specific to LNG IUS clients, and in-depth interviews with LNG IUS clients, providers, and key opinion leaders. RESULTS: Just under 1,000 LNG IUS were inserted from September 2016 to December 2017 in 16 states in channels supported by MSION, representing 0.4% of all long-acting and reversible contraceptive (LARC) services provided by the participating providers during this time frame. The vast majority (82%) of LARCs provided were implants. A small pool of providers was responsible for providing almost half of the LNG IUS services. Common reasons for women choosing the LNG IUS were reduced menstrual bleeding (61%), long-acting duration (52%), effectiveness (49%), and discreetness (42%). Almost 80% of the users first heard about the method from a provider. Almost all users and providers reported positive experiences with the method, noting the noncontraceptive benefits and fewer side effects compared with other methods. All providers who were interviewed said they would continue offering the LNG IUS. Several key opinion leaders mentioned a total market approach incorporating both public and private sectors would be needed to successfully scale up the LNG IUS. CONCLUSION: Reduced menstrual bleeding and fewer side effects compared with other methods were identified as important attributes of the LNG IUS by clients, providers, and key opinion leaders. Challenges to uptake of the LNG IUS include difficulty with introducing a new method within a busy service delivery infrastructure and limited awareness and demand-generation activities on the LNG IUS specifically. A comprehensive product introduction approach with coordinated demand- and supply-side activities may be required for this method to reach its full potential.

Contraceptive use and unintended pregnancy among young women and men in Accra, Ghana.

The objective of this study was to determine factors associated with modern contraceptive use and unintended pregnancy among young women and men in Accra, Ghana. From September-December 2013, we conducted a cross-sectional survey with 250 women and 100 men aged 18-24. We explored determinants of modern contraceptive use among males and females and unintended pregnancy among females. Descriptive statistics, chi-square tests, Fisher's exact tests, and multivariable logistic regression were used. Participants had an average of three lifetime sexual partners, and 91% had one current partner. Overall, 44% reported current modern contraceptive use. In multivariate modeling, modern contraceptive use was associated with higher education compared to primary (AORs 2.1-4.3); ever talking with someone about contraception (AOR 4.7); feeling unsupported by a healthcare provider for contraception (AOR 2.2); and not feeling at risk of unintended pregnancy (AOR 2.7). While ≥70% of participants recognized most contraceptive methods, awareness of some methods was lacking. Nearly all respondents (91%) felt at least one modern method was unsafe. Nearly half of all females (45%) reported their last pregnancy was unintended, and 63% of females and 58% of males felt at risk for future unintended pregnancy. Women were more likely to experience unintended pregnancy if they had ever given birth (AOR 6.7), their sexual debut was 8-14 years versus 20-24 years (AOR 3.4), or they had 3-4 lifetime sexual partners versus 1-2 (AOR 2.4). Targeted interventions are needed to improve understanding of the safety of modern contraceptive methods, increase awareness of long-acting methods, and consequently increase modern contraceptive access and use.

Increasing Access to Family Planning Choices Through Public-Sector Social Franchising: The Experience of Marie Stopes International in Mali.

BACKGROUND: Mali has one of the world's lowest contraceptive use rates and a high rate of unmet need for family planning. In order to increase access to and choice of quality family planning services, Marie Stopes International (MSI) Mali introduced social franchising in public-sector community health centers (referred to as CSCOMs in Mali) in 3 regions under the MSI brand BlueStar. PROGRAM DESCRIPTION: Potential franchisees are generally identified from CSCOMs who have worked with MSI outreach teams; once accredited as franchisees, CSCOMs receive training, supervision, family planning consumables and commodities, and support for awareness raising and demand creation. To ensure availability and affordability of services, franchisees are committed to providing a wide range of contraceptive methods at low fixed prices. METHODS AND RESULTS: The performance of the BlueStar network from inception in March 2012 until December 2015 was examined using information from routine monitoring data, clinical quality audits, and client exit interviews. During this period, the network grew from 70 to 135 franchisees; an estimated 123,428 clients received voluntary family planning services, most commonly long-acting reversible methods of contraception. Franchisee efficiency and clinical quality of services increased over time, and client satisfaction with services remained high. One-quarter of clients in 2015 were under 20 years old, and three-quarters were adopters of family planning (that is, they had not been using a modern method during the 3 months prior to their visit). CONCLUSION: Applying a social franchising support package, originally developed for for-profit private-sector providers, to public-sector facilities in Mali has increased access, choice, and use of family planning in 3 regions of Mali. The experience of BlueStar Mali suggests that interventions that support quality supply of services, while simultaneously addressing demand-side barriers such as service pricing, can successfully create demand for a broad range of family planning services, even in settings with low contraceptive prevalence.

Vouchers for family planning and sexual and reproductive health services: a review of voucher programs involving Marie Stopes International among 11 Asian and African countries.

OBJECTIVES: To evaluate provision of vouchers for family planning and sexual and reproductive health (SRH) services. METHODS: A review was conducted to assess the effects of 24 voucher programs in Marie Stopes International programs across 11 countries in Asia and Africa between 2005 and the present. The outcome measures were uptake of services; service use among specific subgroups; user satisfaction with service quality; and efficiency of service delivery. RESULTS: Twelve of the 24 programs covered family planning only, whereas the other 12 programs covered family planning and/or SRH. Service uptake increased following implementation, although voucher redemption rates varied by program (44.1%-92.4%). Most programs were successful in reaching subgroups, such as the poor and young (under 25years), although this outcome depended on the targeting approach. Most programs recorded high user satisfaction; however, the evidence regarding efficiency was mixed. CONCLUSIONS: Vouchers increased uptake of services and, in some cases, improved service quality and reach to specific groups. Nevertheless, robust evaluation designs are required to measure efficiency.