Need for Standardized Measure of Modern Method Availability: Assessment of Indicators Using Health Facility Data from Three Country Contexts.

The concept of contraceptive method choice is complex and difficult to measure, usually requiring multiple metrics that represent the service environment, access, and acceptability. One of the most used measures for the family planning service delivery environment is method availability, or specifically, the contraceptive options that are available to clients at any given family planning service delivery point. Despite the importance of the measure, indicator definitions vary widely and are not standardized. We identified six versions of the method availability indicator and calculated each version using Service Provision Assessment data from three countries with varying family planning profiles, health service structures, and from different geographic areas: Bangladesh, the Democratic Republic of Congo, and Haiti. We compared method availability estimates by urban/rural location, facility type, and across country context. Our results showed a wide variability in method availability estimates depending on the indicator used. Generally, indicators requiring a particular mix of method types had lower estimates of method availability than indicators only requiring a minimum number of methods. Results are discussed and recommendations are made to standardize indicator language and guidance. We further recommend the standardization of an indicator with a minimum mix of method types to ensure that a variety of method preferences can be met.

Differences by age group in gender-related attitudes in Oromia, Ethiopia: Findings from a cross-sectional study of women of reproductive age.

Attitudes on gender roles affect decision-making dynamics, resource distribution, and income-generating opportunities. However, little is known about how attitudes on gender roles differ by age group. Cross-sectional data collected from 1,113 households in Oromia, Ethiopia were used to assess differences in gender-related attitudes across female "youth" (ages 15-24), "young adults" (ages 25-34), and "older adults" (ages 35-49). Fifteen survey questions using a Likert scale measured attitudes on sexual and reproductive behaviors, expectations around livelihood activities, and perceived influence in household decision making. Associations between attitudes and age group were assessed using the Chi-squared test. Measures of perceived influence in decision making differed significantly by age group for household decisions about participation in wage employment, and use of revenue generated from wage employment, and crop and livestock production. Response patterns were consistent, with youth least likely to feel they have influence in decision making. The results suggest that policies and programs should continue to support the agency of female youth.

Return to pregnancy after contraceptive discontinuation to become pregnant: a pooled analysis of West and East African populations.

BACKGROUND: The fear of infertility or delayed return to fertility is a common barrier to contraceptive use in sub-Saharan Africa, particularly among young or nulliparous women. Global evidence on return to pregnancy after method discontinuation suggests these fears may be misplaced; yet the topic has not been widely studied in sub-Saharan Africa nor by age and parity group. METHODS: Reproductive calendar data from recent Demographic and Health Surveys of 15 sub-Saharan African countries were used to analyze time-to-pregnancy following discontinuation of a contraceptive method with the reason to become pregnant. The probability of pregnancy at 12 months was estimated using single-decrement life tables run by type of method discontinued, age and parity. Results are presented by region: francophone West Africa, anglophone West Africa and East Africa. RESULTS: The 12-month probability of pregnancy after discontinuation of contraception to become pregnant was 73.0% in francophone West Africa, 78.8% in anglophone West Africa, and 82.0% in East Africa. Our results showed significant regional differences in return to pregnancy by 12 months, with probabilities in francophone West Africa being significantly lower than in anglophone West Africa or East Africa. A lower return to pregnancy by 12 months was seen among women ages 35-49 years and was lowest after discontinuation of a hormonal method for all age groups. Differences by parity group were only evident after discontinuation of hormonal methods in francophone West Africa. CONCLUSIONS: Sustainable gains in increasing contraceptive uptake, especially among youth, may be difficult to achieve without information and counseling that address concerns about infertility and potential delays in return to pregnancy following use of hormonal methods.

The fear of infertility or delayed return to fertility is a common barrier to contraceptive use in sub-Saharan Africa, particularly among young or childless women. Global evidence on the time it takes to become pregnant after the discontinuation of a contraceptive method suggests these fears may be misplaced; yet the topic has not been widely studied in sub-Saharan Africa. Data from recent Demographic and Health Surveys of 15 sub-Saharan African countries were used to analyze the time it takes to become pregnant after discontinuation of a contraceptive method with the reason to become pregnant. The probability of becoming pregnant by 12 months was estimated using a life table approach. Results were compared by type of method discontinued, age and whether women had any children, in three regions of sub-Saharan Africa. Our findings show that the 12-month probability of pregnancy after discontinuation of contraception to become pregnant was 73.0% in francophone West Africa, 78.8% in anglophone West Africa, and 82.0% in East Africa. A lower return to pregnancy by 12 months was seen among women ages 35­49 years and was lowest after discontinuation of a hormonal method for all age groups. Differences by whether women had any children were only evident after discontinuation of hormonal methods in francophone West Africa. The findings indicate that sustainable gains in increasing contraceptive uptake, especially among youth, may be difficult to achieve without information and counseling that address concerns about infertility and potential delays in return to pregnancy following use of hormonal methods.

Evaluation of mainstreaming youth-friendly health in private clinics in Malawi.

BACKGROUND: High fertility rates and low modern contraceptive use put African youth and adolescents at high risk for health complications, including maternal mortality. Mainstreaming youth-friendly health services (YFHS) into existing services is one approach to improve access to reproductive health services for youth and adolescents. The objective of the evaluation was to assess the effects of a Population Services International (PSI)-sponsored YFHS training package on voluntary uptake of family planning among youth and perceptions of service quality by youth and trained healthcare providers in Malawi. METHODS: In 2018, a mixed-methods convergent parallel design was used to assess relevant monitoring and evaluation documents and service statistics from PSI Malawi and qualitative data on perceptions of service quality from Malawian youth and healthcare providers. The data were assessed through separate descriptive and thematic analysis and integrated to generate conclusions. RESULTS: Results show that the number of family planning clients ages 15-24 increased from 72 to 2278 per quarter during the implementation of the YFHS training packages, however, positive trends in client numbers were not sustained after youth outreach activities ended. Focus group discussions with 70 youth and adolescents indicated that clinics were perceived as providing high-quality services to youth. The main barriers to accessing the services were cost and embarrassment. Interviews with ten healthcare providers indicated that many made efforts to improve clinic accessibility and understood the barrier of cost and importance of outreach to youth and the broader community. CONCLUSIONS: The findings support research showing positive effects of mainstreaming YFHS when training for healthcare staff is combined with additional YFHS programming components. Furthermore, the findings provide evidence that provider training alone, though beneficial to perceived service quality, is not sufficient to sustain increases in the number of adolescent and youth family planning clients.

Attitudes and Opinions of Young People in Mali on Family Planning, Barriers to Contraceptive Use, and Suggestions for Programming.

The purpose of the research was to investigate Malian youth's attitudes and opinions about Family Planning (FP), barriers to contraceptive use, and suggestions for FP programming. Qualitative data were collected in focus group discussions (FGD) held with 95 females and males ages 18-24 in the district towns of Kita, Kolokani, Mopti, Sikasso, and Tombouctou. Qualitative thematic content analysis techniques were used to analyze the data. Benefits of FP use were acknowledged; however, it was still considered a taboo topic, especially for unmarried youth. This makes it difficult for youth to access information and services. Many participants expressed a desire to learn more about FP, though they underscored the need for confidential and discrete services. Programming suggestions included improving access to information, raising community awareness, and improving access to methods. The study findings can be used to improve messaging, counseling, outreach, and communication, to improve youth's reproductive health in Mali.

Quality of family planning services in HIV integrated and non-integrated health facilities in Malawi and Tanzania.

BACKGROUND: The integration of family planning (FP) and HIV-related services is common in sub-Saharan Africa. Little research has examined how FP quality of care differs between integrated and non-integrated facilities. Using nationally representative data from Malawi and Tanzania, we examined how HIV integration was associated with FP quality of care. METHODS: Data were drawn from Service Provision Assessments (SPAs) from Malawi (2013-2014) and Tanzania (2014-2015). The analytic sample was restricted to lower-level facilities in Malawi (n = 305) and Tanzania (n = 750) that offered FP services. We matched SPA measures to FP quality of care indicators in the Quick Investigation of Quality (QIQ). We conducted bivariate and multivariate analyses of 22 QIQ indicators to examine how integration status was related to individual QIQ indicators and overall FP quality of care at the facility- and client-level. RESULTS: The prevalence of HIV integration in Malawi (39%) and Tanzania (38%) was similar. Integration of HIV services was significantly associated (p < 0.05) with QIQ indicators in Malawi (n = 3) and Tanzania (n = 4). Except for one negative association in Tanzania, all other associations were positive. At the facility-level, HIV integration was associated with increased odds of being at or above the median in FP quality of care in Malawi (adjusted odd ratio (OR) = 2.24; 95% confidence interval (CI) = 1.32, 3.79) and Tanzania (adjusted OR = 2.10; 95% CI = 1.37, 3.22). At the client-level, HIV integration was not associated with FP quality of care in either country. CONCLUSION: Based on samples in Malawi and Tanzania, HIV integration appears to be beneficially associated with FP quality of care. Using a spectrum of FP quality of care indicators, we found little evidence to support concerns that HIV integration may strain facilities and providers, and adversely impact quality outcomes. Rather, it appears to strengthen FP service delivery by increasing the likelihood of stocked FP commodities and achievement of other facility-level quality indicators, potentially through HIV-related supply chains. Further research is needed to assess FP quality of care outcomes across the various platforms of FP integration found in sub-Saharan Africa.

Women's contraceptive discontinuation and switching behavior in urban Senegal, 2010-2015.

BACKGROUND: With the focus of global and national family planning initiatives on reaching "additional user" targets, it is increasingly important for programs to assess contraceptive method discontinuation and switching. This analysis calculated the discontinuation rate and method-specific discontinuation rates, examined reasons given for contraceptive discontinuation, and assessed characteristics associated with subsequent contraceptive switching and abandonment among women living in urban areas of Senegal. METHODS: Data came from the Measurement, Learning & Evaluation project's 2015 survey of 6927 women of reproductive age living in six urban sites (Dakar, Pikine, Guédiawaye, Mbao, Kaolack and Mbour). Information on contraceptive use and discontinuation for the five years preceding the survey were recorded in a monthly calendar. Single decrement life tables were used to calculate discontinuation rates. Descriptive analyses were used to assess reasons for discontinuation and method switching after discontinuation. A multinomial logistic regression was used to estimate the likelihood of being a non-user in-need of contraception, a non-user not in-need of contraception, or a method switcher in the month after discontinuation, by sociodemographic and other characteristics. RESULTS: The 12-month discontinuation rate for all methods was 34.7%. Implants had the lowest one-year discontinuation rates (6.3%) followed by the intrauterine device (IUD) (18.4%) while higher rates were seen for daily pills (38%), injectables (32.7%), and condoms (62.9%). The most common reasons for discontinuation were reduced need (45.6%), method problems (30.1%), and becoming pregnant while using (10.0%). Only 17% of discontinuations were followed by use of another method; most often daily pills (5.2%) or injectables (4.2%). In the multivariate analysis, women with any formal education (primary, secondary or higher) were more than 50% more likely to switch methods than remain in need of contraception after discontinuation than women with no education or Koranic-only education (RRR = 1.59, p-value = 0.004; RRR = 1.55, p-value = 0.031). The likelihood of switching compared to being "in need" was also significantly higher for women who were married and who discontinued traditional methods. CONCLUSIONS: To support increased contraceptive method use, women with no education and unmarried women are priorities for counseling and information about side effects and method switching at the time of method adoption.

Availability of family planning services and quality of counseling by faith-based organizations: a three country comparative analysis.

BACKGROUND: Faith-based organizations (FBOs) have a long history of providing health services in developing countries and are important contributors to healthcare systems. Support for the wellbeing of women, children, and families is evidenced through active participation in the field of family planning (FP). However, there is little quantitative evidence on the availability or quality of FP services by FBOs. METHODS: The descriptive analysis uses facility-level data collected through recent Service Provision Assessments in Malawi (2013-14), Kenya (2010), and Haiti (2012) to examine 11 indicators of FP service and method availability and nine indicators of comprehensive and quality counseling. The indicators include measures of FP service provision, method mix, method stock, the provision of accurate information, and the discussion of reproductive intentions, client's questions/concerns, prevention of sexually transmitted infections, and return visits, among others. Pearson's Chi-square test is used to assess the selected indicators by managing authority (FBO, public, and other private sector) to determine statistical equivalence. RESULTS: Results show that FBOs are less likely to offer FP services than other managing authorities (p < 0.05). For example, 69% of FBOs in Kenya offer FP services compared to 97% of public facilities and 83% of other private facilities. Offering long-acting or permanent methods in faith-based facilities is especially low (43% in Malawi, 29% in Kenya and 39% in Haiti). There were few statistically significant differences between the managing authorities in comprehensive and quality counseling indicators. Interestingly, Haitian FBOs often perform as well or better than public sector health facilities on counseling indicators, such as discussion of a return visit (79% of FBO providers vs. 68% of public sector providers) and discussion of client concerns/questions (52% vs. 49%, respectively). CONCLUSIONS: Results from this analysis indicate that there is room for improvement in the availability of FP services by FBOs in these countries. Quality of counseling should be improved by all managing authorities in the three countries, as indicated by low overall coverage for practices such as ensuring confidentiality (22% in Malawi, 47% in Kenya and 12% in Haiti), discussion of sexually transmitted infections (18%, 25%, 17%, respectively), and providing services to youth (53%, 27%, 32%, respectively).

Understanding patterns of temporary method use among urban women from Uttar Pradesh, India.

BACKGROUND: Almost one in five contraceptive users in India uses a temporary method. It is important to understand user profiles and method use patterns for optimal program targeting.This analysis examines differences in demographic characteristics, discontinuation and use patterns of temporary method users among a representative sample of urban women from four cities in Uttar Pradesh, India. METHODS: Individual data from a panel of women aged 15-49 were collected in 2010 in Agra, Aligarh, Allahabad, and Gorakhpur and follow-up data from the same women were collected in 2012. A contraceptive calendar was used to collect month-by-month data on contraceptive use, non-use, discontinuation, reason for discontinuation, and pregnancy and birth, covering the approximately two-year period between the baseline and midterm surveys. The analysis sample is 4,023 non-sterilized women in union at baseline. A descriptive comparison is made of socio-demographic characteristics, fertility desires, discontinuation, method switching, and pregnancy outcomes. Reasons for discontinuation are assessed by the order of discontinuation. RESULTS: There were a number of socio-demographic differences between users of temporary methods during the calendar period; by education, wealth, and caste. Notably, women who used only condoms during this time had the most education, were the least likely to be poor, and the least likely to be from a scheduled caste or tribe as compared to users of other temporary methods. Compared to the full sample of women, users of temporary methods during this period were less likely to reside in slum areas. The group of multiple method users was small in comparison to the groups of women using a single method throughout the calendar period. This indicates that there was little method switching between condoms, traditional methods, and other forms of modern methods reported in the calendar. CONCLUSIONS: The calendar may not be well-suited to measure coital-dependent contraceptive use (e.g., condoms and traditional methods), as "continuous" monthly use may be overstated. A coital episode-specific data collection tool may produce more accurate records of contraceptive use in such contexts. Research findings also lead to useful programmatic recommendations for addressing unmet need and unintended pregnancies in urban Uttar Pradesh and beyond.

Routine Family Planning Data in the Low- and Middle-Income Country Context: A Synthesis of Findings From 17 Small Research Grants.

Health information systems rely on high-quality data to measure, track, and inform decision making. Currently, the quality, uptake, and use of family planning data in routine health information systems is limited, presenting an opportunity for improvement on many levels. The current synthesis assessed findings from 17 small grants that MEASURE Evaluation issued to low- and middle-income country research teams between 2015 and 2019. Main findings from that research were collaboratively categorized in 4 major themes: (1) the enabling environment for managing and using family planning information; (2) barriers to integration of family planning in routine health information systems; (3) gaps in the analysis, interpretation, and use of routine family planning data; and (4) family planning data use in management, programmatic, and budgetary decisions. Data quality at the systemic, organizational, technical, and output levels was a crosscutting theme. Collectively, the findings outline barriers to and opportunities for improved integration of family planning data and subsequent strengthening of routine health information systems.