Mapping heterogeneity in family planning indicators in Burkina Faso, Kenya, and Nigeria, 2000-2020.

BACKGROUND: Family planning is fundamental to women's reproductive health and is a basic human right. Global targets such as Sustainable Development Goal 3 (specifically, Target 3.7) have been established to promote universal access to sexual and reproductive healthcare services. Country-level estimates of contraceptive use and other family planning indicators are already available and are used for tracking progress towards these goals. However, there is likely heterogeneity in these indicators within countries, and more local estimates can provide crucial additional information about progress towards these goals in specific populations. In this analysis, we develop estimates of six family indicators at a local scale, and use these estimates to describe heterogeneity and spatial-temporal patterns in these indicators in Burkina Faso, Kenya, and Nigeria. METHODS: We used a Bayesian geostatistical modelling framework to analyse geo-located data on contraceptive use and family planning from 61 household surveys in Burkina Faso, Kenya, and Nigeria in order to generate subnational estimates of prevalence and associated uncertainty for six indicators from 2000 to 2020: contraceptive prevalence rate (CPR), modern contraceptive prevalence rate (mCPR), traditional contraceptive prevalence rate (tCPR), unmet need for modern methods of contraception, met need for family planning with modern methods, and intention to use contraception. For each country and indicator, we generated estimates at an approximately 5 × 5-km resolution and at the first and second administrative levels (regions and provinces in Burkina Faso; counties and sub-counties in Kenya; and states and local government areas in Nigeria). RESULTS: We found substantial variation among locations in Burkina Faso, Kenya, and Nigeria for each of the family planning indicators estimated. For example, estimated CPR in 2020 ranged from 13.2% (95% Uncertainty Interval, 8.0-20.0%) in Oudalan to 38.9% (30.1-48.6%) in Kadiogo among provinces in Burkina Faso; from 0.4% (0.0-1.9%) in Banissa to 76.3% (58.1-89.6%) in Makueni among sub-counties in Kenya; and from 0.9% (0.3-2.0%) in Yunusari to 31.8% (19.9-46.9%) in Somolu among local government areas in Nigeria. There were also considerable differences among locations in each country in the magnitude of change over time for any given indicator; however, in most cases, there was more consistency in the direction of that change: for example, CPR, mCPR, and met need for family planning with modern methods increased nationally in all three countries between 2000 and 2020, and similarly increased in all provinces of Burkina Faso, and in large majorities of sub-counties in Kenya and local government areas in Nigeria. CONCLUSIONS: Despite substantial increases in contraceptive use, too many women still have an unmet need for modern methods of contraception. Moreover, country-level estimates of family planning indicators obscure important differences among locations within the same country. The modelling approach described here enables estimating family planning indicators at a subnational level and could be readily adapted to estimate subnational trends in family planning indicators in other countries. These estimates provide a tool for better understanding local needs and informing continued efforts to ensure universal access to sexual and reproductive healthcare services.

Rates of Reproductive Counseling and Contraception Use in Patients with Heart Failure at a Tertiary Care Center.

BACKGROUND: Increasing numbers of women of childbearing age have cardiac disease, including heart failure (HF). In these women, pregnancy can cause significant morbidity and mortality. Contraceptive use and pregnancy counseling in women with HF is an essential part of their medical care. Here, we assess contraceptive use and pregnancy counseling of patients with HF at a single tertiary care center. METHODS AND RESULTS: This was a retrospective, single-center cohort study of female patients with HF with reduced ejection fraction, left ventricular assist devices (LVADs), and heart transplants who were seen in the adult advanced HF outpatient clinics. Patients were identified in the electronic health care record system, and records were reviewed to assess for documentation of contraception and pregnancy counseling. We identified 156 women of childbearing age (aged >18 to <45), seen in the HF clinics between 2018 and 2023. Patients were subdivided by their most recent diagnosis and therapy: HF with reduced ejection fraction (83 [53.2%]), LVAD (18 [11.5%]), and heart transplant (55 [35.3%]). Contraception was documented for 74% of women with HF, 56% of women with LVAD, and 85% of women with heart transplants. Pregnancy counseling was documented for 18.00% of women with HF, 0.06% of women with LVAD, and 29.00% of women with heart transplants. CONCLUSIONS: In our study, many women with HF, LVAD, or transplant have documented contraceptive therapy; however, pregnancy counseling seems to be limited. This vital aspect of medical care should be available for all patients given potential pregnancy-associated risks.

Fertility desires and sexual behaviours among women recovering from genital fistula repair in Eldoret, Kenya.

OBJECTIVES: The reproductive desire of women following genital fistula repair surgery is complex, varied and often not addressed, although it carries significant consequences. The aim of this study was to better understand the fertility desires and sexual behaviours of women who recently underwent surgical repair of a genital fistula. METHODS: This is a secondary analysis of a retrospective cohort study designed to assess the effectiveness of Beyond Fistula, a reintegration programme for women recovering from genital fistula surgery in Eldoret, Kenya. One hundred women who participated in the Beyond Fistula programme between 2013 and 2019 were interviewed in person regarding future fertility desire, current sexual behaviour and contraceptive use. RESULTS: Among the 79 reproductive-aged women included in this study, 63.3% reported no future desire for pregnancy. Those that desired another pregnancy were significantly younger (48.3% were 18-29 years old vs. 66.0% were 35 years old or more, p = 0.004), had fewer living children (70% had 0-2 children vs. 56% had 3 or more children, p < 0.001), and a lower level of food insecurity (27.6% reported no to marginal insecurity vs. 14%, p = 0.014). Current sexual activity was marginally different between women who did and did not desire future pregnancy (82.8% vs. 66.0%, p = 0.053). Of the 50 women in our study who did not desire pregnancy, 62.0% were sexually active and of these, only 38.7% were preventing pregnancy. Lack of knowledge and access to methods were most commonly cited as barriers to use. CONCLUSIONS: Many women recovering from genital fistula surgery do not desire pregnancy and are sexually active but are not using a method to prevent pregnancy. The potential for post-surgical reintegration programmes to address education and access to contraception is a vital and unmet need to promote reproductive empowerment in this population of women as they reestablish their lives.

Hormonal contraceptives and behavior: Updating the potent state of the nascent science.

Hundreds of millions of people worldwide use hormonal contraceptives (HCs), which have been an essential part of women's reproductive health care for decades. Throughout that time, however, research on the neural and behavioral consequences of HCs was minimal and plagued by poor methodology. HC effects - and users - were assumed to be homogenous. Fortunately, there has been a recent upswell in the number and quality of investigations, affording tentative conclusions about the roles of HCs in spatial cognition and mental health, particularly depression. Thus, this paper leverages findings from the past few years to highlight the heterogeneous aspects of use that seem to matter for behavior - ranging from variation in hormonal contraceptive formulations and routes of administration to individual differences among users linked to age and reproductive health history. This paper closes with five tips for future research that will help capture and clarify heterogeneity in potential relations between HCs and behavior, namely data collection, regional access, lifespan factors, gender, and collaboration. HCs are sociopolitically provocative and research on their potential behavioral neuroendocrine impacts is becoming increasingly popular. It is, therefore, imperative for scientists to conduct replicable and robust empirical investigations, and to communicate findings with the nuance that the heterogeneity among users and effects requires.

The association between postpartum depressive symptoms and contraception.

BACKGROUND: Postpartum depression affects 10% to 20% of birthing people and is associated with changes in healthcare use. Little is known about the association between postpartum depressive symptoms and choice to use contraception; however, both untreated or undertreated depression and short interpregnancy intervals pose substantial perinatal health risks. OBJECTIVE: This study aimed to evaluate whether postpartum depressive symptoms are associated with changes in decisions to use any method of contraception. STUDY DESIGN: This retrospective cohort study included birthing people who delivered between 2017 and 2022 and were referred to a collaborative care program for mental healthcare. Through this program, birthing people with mental health conditions have access to specialized perinatal mental healthcare and prospective symptom monitoring via a patient registry. Postpartum depressive symptoms are assessed via the Patient Health Questionnaire-9, and scores were stratified by severity according to clinical cutoffs. Contraceptive method choice was determined by documentation in the electronic health record and dichotomized as "none" if the participant declined all forms of contraception both at delivery and at the postpartum visit. Bivariable and multivariable analyses were performed. RESULTS: Of the 1871 participants that met the inclusion criteria, 160 (8.5%) had postpartum Patient Health Questionnaire-9 scores of >14, representing moderately severe or worse depressive symptoms, and 43 (2.3%) had severe (Patient Health Questionnaire-9 of >19) depressive symptoms. Birthing people with higher Patient Health Questionnaire-9 scores were more likely to have medical comorbidities; to have a higher body mass index; to self-identify as Black, Native Hawaiian or Pacific Islander, or Hispanic or Latina; and to have a preterm delivery and less likely to be married or nulliparous than those with Patient Health Questionnaire-9 scores of ≤14. There was no difference in any other sociodemographic or clinical characteristics. The choice to use any contraceptive method decreased with increasing depressive symptoms in bivariable and multivariable analyses, reaching statistical significance in birthing people with severe depressive symptoms (adjusted odds ratio, 2.92; 95% confidence interval, 1.46-5.84). CONCLUSION: Severe perinatal depressive symptoms are associated with a declination of any form of postpartum contraception. This finding becomes increasingly relevant as abortion access continues to be threatened across the United States, compounding the potential effect of opting not to use contraception.

Shortcomings and disparities in contraception counseling and use by hypertensive individuals at risk for unintended pregnancy: a comparative analysis of the National Survey of Family Growth.

BACKGROUND: Hypertension is a leading cause of adverse pregnancy outcomes. These outcomes disproportionately affect Black individuals. Reproductive life planning that includes patient-centered contraception counseling could mitigate the impact of unintended pregnancy. OBJECTIVE: The primary objective of the study is to compare contraception counseling and use between hypertensive and nonhypertensive individuals at risk for unintended pregnancy. Our secondary objectives are the following: (1) to evaluate the effect of race on the probability of counseling and the use of contraception, and (2) to evaluate the methods used by individuals with hypertension. METHODS: Data from the 2015-2017 and 2017-2019 National Survey of Family Growth Female Respondent Files were used to analyze whether individuals who reported being informed of having high blood pressure within the previous 12 months received counseling about contraception or received a contraceptive method. Covariates considered in the analysis included age, race, parity, educational attainment, body mass index, smoking, diabetes, and experience with social determinants of health. The social determinants of health covariate was based on reported experiences within 5 social determinants of health domains: food security, housing stability, financial security, transportation access, and childcare needs. Linear probability models were used to estimate the adjusted probability of receiving counseling and the use of a contraceptive. Using difference-in-difference analyses, we compared the change in counseling and use between hypertensive and nonhypertensive respondents by race, relative to White respondents. RESULTS: Of the 8625 participants analyzed, 771 (9%) were hypertensive. Contraception counseling was received by 26.2% (95% confidence interval, 20.4-31.9) of hypertensive individuals and 20.7% (95% confidence interval, 19.3-22.2) of nonhypertensive individuals. Contraception use was reported by 39.8% (95% confidence interval, 33.2-46.5) of hypertensive and 35.3% (95% confidence interval, 33.3-37.2) of nonhypertensive individuals. The linear probability model adjusting for age, parity, education attainment, body mass index, smoking, diabetes, and social determinants of health indicated that hypertensive individuals were 8 percentage points (95% confidence interval, 3-18 percentage points) more likely to receive counseling and 9 percentage points (95% confidence interval, 3-16 percentage points) more likely to use contraception. Hypertensive Black individuals did not receive more counseling or use more contraceptives compared with nonhypertensive Black individuals. The difference in counseling when hypertension was present was 13 percentage points lower than the difference observed for White respondents when hypertension was present (P=.01). The most frequently used contraceptive method among hypertensive individuals was combined oral contraceptive pills (54.0%; 95% confidence interval, 44.3%-63.5%). CONCLUSION: Despite the higher likelihood of receiving contraception counseling and using contraception among hypertensive individuals at risk for unintended pregnancy, two-thirds of this population did not receive contraception counseling, and <40% used any contraceptive method. Furthermore, unlike White individuals, Black individuals with hypertension did not receive more contraception care than nonhypertensive Black individuals. Of all those who used contraception, half relied on a method classified as Centers for Disease Control and Prevention Medical Eligibility Criteria Category 3. These findings highlight a substantial unmet need for safe and accessible contraception options for hypertensive individuals at risk for unintended pregnancy, emphasizing the importance of targeted interventions to improve contraceptive care and counseling in this population.

Frequency of same-day contraceptive initiation, recent unprotected intercourse, and pregnancy risk: a prospective cohort study of multiple contraceptive methods.

BACKGROUND: Same-day start removes barriers to contraceptive initiation and may reduce the risk of unintended pregnancy. It may be appropriate for all contraceptive methods, but we lack data comparing methods. OBJECTIVE: This study aimed to assess the frequency of same-day start with 6 contraceptive methods among new contraceptive users and describe the efficacy of same-day start in terms of first-cycle pregnancy risk overall and by each method. STUDY DESIGN: Using prospective data from the HER Salt Lake Contraceptive Initiative, we identified and assessed outcomes for participants initiating a new method of contraception beyond the first 7 days of their menstrual cycle (same-day start). Enrolled participants at 4 family planning clinics in Salt Lake County, Utah between September 2015 and March 2017 received their method of choice regardless of their cycle day or recent unprotected intercourse. All participants self-reported last menstrual period data and unprotected intercourse events in the previous 2 weeks. We excluded participants who received care immediately after or within 2 weeks of abortion care. Clinical electronic health records provided information on contraceptive method initiation and use of oral emergency contraception. Participants reported pregnancy outcomes in 1-, 3-, and 6-month follow-up surveys with clinic verification to identify any pregnancy resulting from same-day initiation. The primary outcomes report the frequency of same-day start use and first-cycle pregnancy risk among same-day start users of all contraceptive methods. The secondary outcomes include frequency of and pregnancy risk in the first cycle of use among same-day start contraception users by method. We also report the frequency of unprotected intercourse within 5 days and 6 to 14 days of contraception initiation, frequency of concomitant receipt of oral emergency contraception with initiation of ongoing contraception, and pregnancy risk with these exposures. We analyzed pregnancy risk for each contraceptive method initiated on the same day and assessed the simultaneous use of oral emergency contraception. RESULTS: Of the 3568 individuals enrolled, we identified most as same-day start users (n=2575/3568; 72.2%), with 1 in 8 of those reporting unprotected intercourse in the previous 5 days (n=322/2575; 12.5%) and 1 in 10 reporting unprotected intercourse 6 to 14 days before contraceptive method initiation (n=254/2575; 9.9%). We identified 11 pregnancies among same-day start users (0.4%; 95% confidence interval, 0.2-0.7), as opposed to 1 (0.1%; 95% confidence interval, 0.002-0.6) among those who initiated contraception within 7 days from the last menstrual period. Users of oral hormonal contraception and vaginal hormonal methods reported the highest first-cycle pregnancy rates (1.0-1.2). Among same-day start users, 174 (6.8%) received oral emergency contraception at enrollment in conjunction with another method. Among the same-day start users who received emergency contraception at initiation, 4 (2.3%) pregnancies were reported. CONCLUSION: Same-day start is common and associated with a low pregnancy risk. Using the "any method, any-time" approach better meets contraceptive clients' needs and maintains a low risk of pregnancy.

The Impact of a Digital Contraceptive Decision Aid on User Outcomes: Results of an Experimental, Clinical Trial.

BACKGROUND: Nearly 40% of unplanned pregnancies in the USA are the result of inconsistent or incorrect contraceptive use. Finding ways to increase women's comfort and satisfaction with contraceptive use is therefore critical to public health. One promising pathway for improving patient outcomes is through the use of digital decision aids that assist women and their physicians in choosing a contraceptive option that women are comfortable with. Testing the ability of these aids to improve patient outcomes is therefore a necessary first step toward incorporating this technology into traditional physician appointments. PURPOSE: To evaluate the effectiveness of a novel contraceptive decision aid at minimizing decisional conflict and increasing comfort with contraception among adult women. METHODS: In total, 310 adult women were assigned to use either the Tuune contraceptive decision aid or a control aid modeled after a leading online contraceptive prescriber's patient intake form. Participants then completed self-report measures of decisional conflict, contraceptive expectations, satisfaction, and contraceptive use intentions. Individual between-subjects analysis of variance (ANOVA) models were used to examine these outcomes. RESULTS: Women using the Tuune decision aid (vs. those using the control aid) reported lower decisional conflict, more positive contraceptive expectations, greater satisfaction with the decision aid and recommendation, and more positive contraceptive use intentions. CONCLUSIONS: Use of Tuune improved each of the predicted patient outcomes relative to a control decision aid. Online decision aids, particularly when used alongside physician consultations, may be an effective tool for increasing comfort with contraceptive use. CLINICAL TRIALS REGISTRATION #: NCT05177783, ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT05177783.

Digital decision aids that help women and their physicians choose contraceptive options that women are most comfortable with present one promising way to improve contraceptive use outcomes, such as avoiding unplanned pregnancies. However, current decision aids have been found to struggle in helping improve women's satisfaction with and confidence in their contraceptive choices. The aim of this study was to test the effectiveness of a new digital decision aid, named Tuune, at helping improve women's confidence and comfort with contraception. Three hundred and ten adult women were randomly assigned to use and then receive a contraceptive recommendation from either the Tuune decision aid or a control aid designed after leading traditional health intake forms. Women's confidence and satisfaction with the aids, as well as their contraceptive recommendation, were then compared between groups. We found good evidence to suggest that women using the Tuune contraceptive decision aid were more satisfied and positive about their contraceptive choices and reported greater intentions to use contraception with increased confidence compared to women who used the control decision aid. New online decision aids, like Tuune, may be an effective tool for increasing women's comfort and experiences using contraception.

Family Planning Counseling for Women Living with HIV in Low- and Middle-Income Countries: A Systematic Review of the Impact on Contraceptive Uptake, Intention to Use Contraception and Pregnancy Incidence, 2011 to 2022.

Women's ability to control their fertility and have the number of children they want when they want them is an internationally recognized human right. This right has been the driving force behind family planning programs in low- and middle-income countries for more than five decades. The HIV epidemic added greater urgency to those efforts once the risk of vertical transmission of the virus from mothers to their infants was recognized. In 2013, we published a systematic review of the evidence of effectiveness of family planning counseling for women living with HIV, emphasizing HIV related behaviors. In this updated review, we examined 23 studies, primarily from sub-Saharan Africa. The evidence we uncovered reflected efforts to integrate services provided to women. These showed that providing contraceptive services, including intensified counseling and support, in the HIV clinics where women living with HIV received their care increased the likelihood of subsequent use of modern contraception by as much as fourfold. These studies reflected a greater focus on women's family planning decisions and behaviors and less focus on HIV-related behaviors. Among the possible causes of this noted difference we include the widespread coverage of antiretroviral treatment for HIV. This advance has apparently changed the rationale and the approach to integrating family planning and HIV services in ways that may not have been fully appreciated. The results, however, are beneficial: greater coverage of family planning for women who wish to control their fertility and a more equal partnership between family planning services and HIV services in pursuit of the mutual goal of providing integrated services to meet women's needs.

Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study.

OBJECTIVE: To examine the uptake of postnatal contraception (PNC) and experiences of PNC care across a geographical region of England. DESIGN: Cross-sectional online survey. SETTING: The North East and North Cumbria Integrated Care System (ICS). POPULATION: Women who had completed a pregnancy in the previous 3 years. METHODS: The uptake of PNC by accessed method(s) and the availability of preferred method(s) is described, and adjusted odds ratios are reported for group differences in uptake by characteristics of interest. MAIN OUTCOME MEASURES: Uptake of medically prescribed/administered contraception and uptake of long-acting reversible contraception (LARC) during the postnatal period, and access to preferred PNC methods. RESULTS: Although almost half of respondents (47.1%; n = 1178) reinitiated some form of sexual activity during the postnatal period, only 38.7% (n = 969) of respondents accessed a medically prescribed/administered contraceptive method postnatally, and only 15.5% (n = 389) of respondents accessed a LARC. It is a matter of concern that 18.8% (n = 451) of respondents indicated that they were unable to access their preferred PNC. In multivariate analysis, younger age, lower household income, higher multiparity, operative delivery, unplanned pregnancy and not breastfeeding were significant predictors of higher PNC uptake. CONCLUSIONS: The uptake of PNC in this cohort was low, with almost a fifth of women unable to access their preferred method. However, there was some evidence that women belonging to groups perceived to be at risk of rapid repeat pregnancy were more likely to access reliable PNC methods.

A Longitudinal Multilevel Analysis of the Effects of Contraceptive Failures on Unintended Pregnancies among Women in Urban Nigeria.

Unintended pregnancy is a global public health concern. However, the effect of contraceptive failure on unintended pregnancy remains unclear in Nigeria. We undertook a longitudinal analysis to examine the effect of contraceptive failure on unintended pregnancy among urban women in Nigeria. We used panel data from the Nigerian Urban Reproductive Health Initiative. The Measurement, Learning and Evaluation program conducted the surveys among a cohort of women aged 15-49 who were first interviewed at baseline in 2010/2011 and followed up at endline in 2014/2015. Analytic sample was 4140 women aged 15-49 who ever used contraceptives. We fitted three-level multilevel binary logistic regression models estimated with GLLAMM. The study established evidence that there is a significant effect of contraceptive failure on unintended pregnancy among urban women in Nigeria. The positive effect of between-person contraceptive failure indicates that respondents who experienced more contraceptive failure than the average in the sample had 5.26 times higher odds of unintended pregnancy (OR = 5.26; p-value < 0.001). Results also established a significant effect of within-person contraceptive failures among the respondents. Findings suggest there is evidence of a significant longitudinal effect of contraceptive failure on unintended pregnancy in urban Nigeria. Efforts to reduce unintended pregnancy must include interventions to address the problem of contraceptive failure among urban women in Nigeria.

Assessing Trends in the Desire to Avoid Pregnancy: A Cautionary Note.

The desire to avoid pregnancy-to delay the next birth or have no further births-is a fundamental sexual and reproductive health indicator. We show that two readily available measures-prospective fertility preferences and the demand for contraception [Demand] construct-provide substantially different portraits of historical trends. They also yield correspondingly different assessments of the sources of contraceptive change. We argue, with supporting empirical evidence, that Demand enormously overstates the historical trend in the desire to avoid pregnancy because Demand as currently constructed is in part a function of contraceptive prevalence. This makes for "reverse causality" in decompositions of contraceptive change, producing an upward distortion on the order of 25 percentage points in the amount of contraceptive change attributed to a change in fertility desires. Decomposition of contraception change free of the distortion reveals that contraceptive change has been due almost entirely to more complete implementation of fertility preferences. This is explained in part by the surprisingly slight historical change in preferences, a fact we document and then show is a consequence of a historical shift in parity composition toward lower parities.

Men's Willingness to Use and Preferences for Novel Male Contraceptive Methods in Malawi.

Evidence is needed in low- and middle-income countries regarding men's willingness to use new male contraceptive methods in development, preferences regarding method attributes, and what shapes willingness/preferences. We analyzed data from cross-sectional surveys with 611 men in Malawi, concerning willingness to use each of four types of new male methods. Mean age was 24.5 years; half (50 percent) were married/cohabiting. Over half (51 percent) of men expressed willingness to use at least one new male method, including a topical contraceptive gel (33 percent), injection (32 percent), pill (29 percent), and implant (14 percent). Many male product attributes were considered important (with 59-67 percent endorsement), including ease of use, comfort of use, side effects, partner approval, type of method, frequency of facility visits, and cost. A prevalent reported reason for willingness was to "share responsibility for family planning with my partner" (44 percent). In multivariate regression analyses, willingness was inversely associated with inequitable gender attitudes (p < 0.001) and was not associated with married/cohabiting status, using condoms, or perceived risk for HIV. These findings add to growing evidence that a majority of men express willingness to use new male contraceptive methods like a topical gel, injectable, or pill. Reflection around gender roles is likely critical within future education about male contraceptive methods.

Are Contraceptive Method Preferences Stable? Measuring Change in the Preferred Method among Kenyan Women.

Contraceptive preferences are important for reproductive outcomes, such as contraceptive continuation and pregnancy. Current approaches to measuring reproductive preferences in population surveys are limited to exploring only fertility preferences and implicitly assume that contracepting people are using a method they want. We know that people change their fertility preferences over the life course as a response to life events, but there is no information about changes in contraceptive preferences, given the limited evidence about the measurement and distribution of contraceptive preferences. In this study, we examined the extent of change in women's contraceptive preferences over one year and identified characteristics associated with this change in Kenya using three rounds of nationally representative longitudinal data. Over one year, 18 percent of contraceptive users and 46 percent of contraceptive nonusers reported changes in their preferred contraceptive. Experiencing a pregnancy or birth and changes in marital status were associated with changes in contraceptive preferences for users and nonusers. We found that contraceptive preferences are dynamic, suggesting that family planning programs should ensure people's access to various methods to respond to women's changing circumstances and preferences.

The Relationships between Drought Exposure, Fertility Preferences, and Contraceptive Behaviors: A Multicountry Study.

The interplay between population dynamics and the environment has long interested demographers. Although studies have explored how climate patterns affect macrolevel population processes, such as mortality and migration, little is known about their impact on individual-level demographic behaviors. This study fills this research gap by examining the linkages between exposure to drought and women's fertility preferences and contraceptive behaviors in sub-Saharan Africa. We analyze data from the Demographic and Health Surveys Program, focusing on 17 countries in East, Southern, and West Africa. We investigate whether women's recent exposure to drought episodes in their community affects their fertility preferences and modern contraceptive use. Generally, the findings show that drought is relevant to understanding women's fertility preferences and behaviors in the vast majority of countries; however, drought exposure has variable impacts. Moreover, whereas in some countries, drought exposure encourages contraceptive behaviors that align with women's preferences, in select countries it is associated with behavior that is misaligned with women's stated preferences. Overall, the study emphasizes the importance of examining climate events as complex forces that have localized meanings for demographic outcomes.

There's an App for That: Exploring the Market for Contraceptive Fertility Tracking Apps in the Philippines.

For generations, women have relied on fertility awareness methods to plan and prevent pregnancy, for over a decade, many have been aided by digital tools to do so. New contraceptive fertility tracking apps (CFTAs)-that are backed by clinical efficacy trials to support their effectiveness as contraception-have the potential to enhance method choice and offer users a unique contraceptive option, but there is little evidence to inform the decisions around expanding access, particularly in low-and middle-income countries. We conducted a mixed methods study with quantitative online surveys (n = 1600) and qualitative interviews (n = 36) to explore the potential appeal of and demand for a hypothetical CFTA in one such market, the Philippines. Interest in using a CFTA was high among our Internet-engaged, urban study population, with 83.9% "definitely" or "probably" interested in using it. Across demographic profiles, respondents perceived the appeal of the method as "natural" and "convenient." A majority were willing to pay for the method, though notably at a price (5.20 USD) below that of currently available CFTAs. We discuss various important factors to be considered before bringing a method like this to new markets, including the potential implications of equity constraints in reaching a wider market and the unexpected prevalence of other period-tracking apps not intended as contraception being used in this market that could complicate any future roll-out. These issues could be explored further with additional research.

Confirmatory Factor Analysis and Validation of the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults in Kenya.

Understanding the levels of power that adolescent girls and young women exercise in their sexual and reproductive lives is imperative to inform interventions to help them meet their goals. We implemented an adapted version of the Sexual and Reproductive Health Empowerment (SRE) Scale for Adolescents and Young Adults among 500 adolescent girls and young women aged 15-20 in Kisumu, Kenya. We used confirmatory factor analysis (CFA) to assess factor structure, and logistic regression to examine construct validity through the relationship between empowerment scores and ability to mitigate risk of undesired pregnancy through consistent contraceptive use. Participants had a mean age of 17.5, and most were students (61 percent), were currently partnered (94 percent), and reported having sex in the past 3 months (70 percent). The final, 26-item CFA model had acceptable fit. All subscales had Cronbach's alpha scores >0.7, and all items had rotated factor loadings >0.5, indicating good internal consistency and robust factor-variable associations. The total SRE-Kenya (SRE-K) score was associated with increased odds of the consistent method used in the past three months (adjusted odds ratio: 1.98, 95 percent CI: 1.29-3.10). The SRE-K scale is a newly adapted and valid measure of sexual and reproductive empowerment specific to adolescent girls and young women in an East African setting.

Effects of Performance-Based Financing on Availability, Quality, and Use of Family Planning Services in the Democratic Republic of Congo: An Impact Evaluation.

Access to high-quality family planning services remains limited in many low- and middle-income countries, resulting in a high burden of unintended pregnancies and adverse health outcomes. We used data from a large randomized controlled trial in the Democratic Republic of Congo to test whether performance-based financing (PBF) can increase the availability, quality, and use of family planning services. Starting at the end of 2016, 30 health zones were randomly assigned to a PBF program, in which health facilities received financing conditional on the quantity and quality of offered services. Twenty-eight health zones were assigned to a control group in which health facilities received unconditional financing of a similar magnitude. Follow-up data collection took place in 2021-2022 and included 346 health facility assessments, 476 direct clinical observations of family planning consultations, and 9,585 household surveys. Findings from multivariable regression models show that the PBF program had strong positive impacts on the availability and quality of family planning services. Specifically, the program increased the likelihood that health facilities offered any family planning services by 20 percentage points and increased the likelihood that health facilities had contraceptive pills, injectables, and implants available by 23, 24, and 20 percentage points, respectively. The program also improved the process quality of family planning consultations by 0.59 standard deviations. Despite these improvements, and in addition to reductions in service fees, the program had a modest impact on contraceptive use, increasing the modern method use among sexually active women of reproductive age by 4 percentage points (equivalent to a 37 percent increase), with no significant impact on adolescent contraceptive use. These results suggest that although PBF can be an effective approach for improving the supply of family planning services, complementary demand-side interventions are likely needed in a setting with very low baseline utilization.

Continuation of Reversible Contraception Following Enrollment in the Zika Contraception Access Network (Z-CAN) in Puerto Rico, 2016-2020.

The Zika Contraception Access Network (Z-CAN) provided access to high-quality client-centered contraceptive services across Puerto Rico during the 2016-2017 Zika virus outbreak. We sent online surveys during May 2017-August 2020 to a subset of Z-CAN patients at 6, 24, and 36 months after program enrollment (response rates: 55-60 percent). We described contraceptive method continuation, method satisfaction, and method switching, and we identified characteristics associated with discontinuation using multivariable logistic regression. Across all contraceptive methods, continuation was 82.5 percent, 64.2 percent, and 49.9 percent at 6, 24, and 36 months, respectively. Among continuing users, method satisfaction was approximately ≥90 percent. Characteristics associated with decreased likelihood of discontinuation included: using an intrauterine device or implant compared with a nonlong-acting reversible contraceptive method (shot, pills, ring, patch, or condoms alone); wanting to prevent pregnancy at follow-up; and receiving as their baseline method the same method primarily used before Z-CAN. Other associated characteristics included: receiving the method they were most interested in postcounseling (6 and 24 months) and being very satisfied with Z-CAN services at the initial visit (6 months). Among those wanting to prevent pregnancy at follow-up, about half reported switching to another method. Ongoing access to contraceptive services is essential for promoting reproductive autonomy, including supporting patients with continued use, method switching, or discontinuation.

Depression, Contraception, and Ambivalence Concerning Fertility.

Individuals suffering from depression exhibit a higher rate of unintended pregnancies, which are associated with negative outcomes for both parents and children. Often, unintended pregnancies result from contraceptive mistakes. Here, we examine the relationship between depression and the consistency of contraceptive behavior, testing ambivalence as a possible mediator. The analyses were based on cross-sectional data from the second and third waves of the German Relationship and Family Panel Pairfam. A German-speaking sample without children (N = 190; 117 female, 73 male), who reported not attempting to conceive or become pregnant during the last 12 months, was analyzed in comparison with a propensity score matched sample. Ambivalence was operationalized as the difference between the ideal and realistic number of children in wave 2. Data from wave 3 were used to assess contraceptive behavior. Depressed mood in wave 2 and consistency of contraceptive behavior in wave 3 were negatively correlated. After including ambivalence in wave 2 as a mediator in the model, the direct path between depressed mood and consistency of contraceptive behavior remained significant, with no significant mediation found. For men only, we observed a significant negative association of ambivalence with the consistency of contraceptive behavior in the last 3 months. No significant relationship was found between depressed mood and ambivalence. We conclude that future research aiming to better understand the consistency of contraceptive behavior should incorporate measures of ambivalence.