Contribution of Contraceptive Discontinuation to Unintended Births in 36 Developing Countries.

High contraceptive discontinuation results in millions of women having an unmet need for contraception. However, its contribution to unintended fertility is not known. Reproductive calendar data in Demographic and Health Surveys in 36 countries are used to estimate the percent of unintended recent births attributable to contraceptive discontinuation. Contraceptive discontinuation accounted for about one-third of unintended recent births in all countries together. Method failure and contraception discontinued for other reasons accounted for most of this contribution. The contribution of contraceptive discontinuation to unintended births increases with the use of modern methods but decreases as method composition at a given level of contraceptive prevalence shifts toward methods with higher effectiveness and longer continuation. High contraceptive discontinuation in the past without changes in fertility intentions has resulted in millions of unintended births. This contribution is likely to increase with the anticipated increase in the use of modern methods. Enabling current users to reduce method failure and encouraging them to switch to another method after discontinuing the use of the original method will be an effective strategy to reduce contraceptive discontinuation and its contribution to unintended births.

The effects of family planning and other factors on fertility, abortion, miscarriage, and stillbirths in the Spectrum model.

BACKGROUND: The Lives Saved Tool (LiST) estimates the effects of maternal and child health interventions on mortality rates and the number of deaths. The family planning module in Spectrum interacts with LiST by providing estimates of the effects of scaling up family planning use on the number of live births, miscarriages, abortions, and stillbirths. METHODS: We use the proximate determinants of fertility framework to estimate the effects of changes in contraceptive use, proportion married, postpartum insusceptibility, abortion and sterility on the total fertility rate. We extend this framework to estimate the number of intended and unintended pregnancies and the resulting live births, abortions, stillbirths, and miscarriages. RESULTS: We apply the model to four countries (Mali, Kenya, Indonesia, and Ukraine) to demonstrate possible trends with a range of family planning and fertility levels. In high-fertility countries, such as Mali, increases in contraceptive use will partially compensate for the increasing number of women of reproductive age to reduce the annual increases in pregnancies and births. Most unintended pregnancies occur to women defined as having unmet need for contraception. In low-fertility countries, increases in contraceptive use may reduce abortion rates and low levels of unmet need mean that most unintended pregnancies are due to method failure. CONCLUSIONS: The family planning module in Spectrum provides a useful framework to incorporate changes in contraceptive practices and pregnancy outcomes in the LiST calculations of mortality rates and deaths.

Lives Saved Tool (LiST) costing: a module to examine costs and prioritize interventions.

BACKGROUND: Achieving the Sustainable Development Goals will require careful allocation of resources in order to achieve the highest impact. The Lives Saved Tool (LiST) has been used widely to calculate the impact of maternal, neonatal and child health (MNCH) interventions for program planning and multi-country estimation in several Lancet Series commissions. As use of the LiST model increases, many have expressed a desire to cost interventions within the model, in order to support budgeting and prioritization of interventions by countries. A limited LiST costing module was introduced several years ago, but with gaps in cost types. Updates to inputs have now been added to make the module fully functional for a range of uses. METHODS: This paper builds on previous work that developed an initial version of the LiST costing module to provide costs for MNCH interventions using an ingredients-based costing approach. Here, we update in 2016 the previous econometric estimates from 2013 with newly-available data and also include above-facility level costs such as program management. The updated econometric estimates inform percentages of intervention-level costs for some direct costs and indirect costs. These estimates add to existing values for direct cost requirements for items such as drugs and supplies and required provider time which were already available in LiST Costing. RESULTS: Results generated by the LiST costing module include costs for each intervention, as well as disaggregated costs by intervention including drug and supply costs, labor costs, other recurrent costs, capital costs, and above-service delivery costs. These results can be combined with mortality estimates to support prioritization of interventions by countries. CONCLUSIONS: The LiST costing module provides an option for countries to identify resource requirements for scaling up a maternal, neonatal, and child health program, and to examine the financial impact of different resource allocation strategies. It can be a useful tool for countries as they seek to identify the best investments for scarce resources. The purpose of the LiST model is to provide a tool to make resource allocation decisions in a strategic planning process through prioritizing interventions based on resulting impact on maternal and child mortality and morbidity.

Impact of malaria interventions on child mortality in endemic African settings: comparison and alignment between LiST and Spectrum-Malaria model.

BACKGROUND: In malaria-endemic countries, malaria prevention and treatment are critical for child health. In the context of intervention scale-up and rapid changes in endemicity, projections of intervention impact and optimized program scale-up strategies need to take into account the consequent dynamics of transmission and immunity. METHODS: The new Spectrum-Malaria program planning tool was used to project health impacts of Insecticide-Treated mosquito Nets (ITNs) and effective management of uncomplicated malaria cases (CMU), among other interventions, on malaria infection prevalence, case incidence and mortality in children 0-4 years, 5-14 years of age and adults. Spectrum-Malaria uses statistical models fitted to simulations of the dynamic effects of increasing intervention coverage on these burdens as a function of baseline malaria endemicity, seasonality in transmission and malaria intervention coverage levels (estimated for years 2000 to 2015 by the World Health Organization and Malaria Atlas Project). Spectrum-Malaria projections of proportional reductions in under-five malaria mortality were compared with those of the Lives Saved Tool (LiST) for the Democratic Republic of the Congo and Zambia, for given (standardized) scenarios of ITN and/or CMU scale-up over 2016-2030. RESULTS: Proportional mortality reductions over the first two years following scale-up of ITNs from near-zero baselines to moderately higher coverages align well between LiST and Spectrum-Malaria -as expected since both models were fitted to cluster-randomized ITN trials in moderate-to-high-endemic settings with 2-year durations. For further scale-up from moderately high ITN coverage to near-universal coverage (as currently relevant for strategic planning for many countries), Spectrum-Malaria predicts smaller additional ITN impacts than LiST, reflecting progressive saturation. For CMU, especially in the longer term (over 2022-2030) and for lower-endemic settings (like Zambia), Spectrum-Malaria projects larger proportional impacts, reflecting onward dynamic effects not fully captured by LiST. CONCLUSIONS: Spectrum-Malaria complements LiST by extending the scope of malaria interventions, program packages and health outcomes that can be evaluated for policy making and strategic planning within and beyond the perspective of child survival.

Reassessing Unmet Need for Family Planning in the Postpartum Period.

Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times: right after delivery (prospective indicator), after six months of amenorrhea (intermediate indicator), and at the end of amenorrhea (classic indicator). DHS data from 57 countries in 2005-13 indicate that 62 percent (prospective), 43 percent (intermediate), and 32 percent (classic) of women in the first year after a birth have an unmet need for contraception (40 percent when including abstinence). While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods' widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.

Heart failure management at home: a non-randomised prospective case-controlled trial (HeMan at Home).

BACKGROUND/OBJECTIVES: Heart failure (HF) is a growing clinical and economic burden for patients and health systems. The COVID-19 pandemic has led to avoidance and delay in care, resulting in increased morbidity and mortality among many patients with HF. The increasing burden of HF during the COVID-19 pandemic led us to evaluate the quality and safety of the Hospital at Home (HAH) for patients presenting to their community providers or emergency department (ED) with symptoms of acute on chronic HF (CHF) requiring admission. DESIGN/OUTCOMES: A non-randomised prospective case-controlled of patients enrolled in the HAH versus admission to the hospital (usual care, UC). Primary outcomes included length of stay (LOS), adverse events, discharge disposition and patient satisfaction. Secondary outcomes included 30-day readmission rates, 30-day ED usage and ED dwell time. RESULTS: Sixty patients met inclusion/exclusion criteria and were included in the study. Of the 60 patients, 40 were in the HAH and 20 were in the UC group. Primary outcomes demonstrated that HAH patients had slightly longer LOS (6.3 days vs 4.7 days); however, fewer adverse events (12.5% vs 35%) compared with the UC group. Those enrolled in the HAH programme were less likely to be discharged with postacute services (skilled nursing facility or home health). HAH was associated with increased patient satisfaction compared with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score in North Carolina. Secondary outcomes of 30-day readmission and ED usage were similar between HAH and UC. CONCLUSIONS: The HAH pilot programme was shown to be a safe and effective alternative to hospitalisation for the appropriately selected patient presenting with acute on CHF.

Methods used in the Lives Saved Tool (LiST).

BACKGROUND: Choosing an optimum set of child health interventions for maximum mortality impact is important within resource poor policy environments. The Lives Saved Tool (LiST) is a computer model that estimates the mortality and stillbirth impact of scaling up proven maternal and child health interventions. This paper will describe the methods used to estimate the impact of scaling up interventions on neonatal and child mortality. MODEL STRUCTURE AND ASSUMPTIONS: LiST estimates mortality impact via five age bands 0 months, 1-5 months, 6-11 months, 12-23 months and 24 to 59 months. For each of these age bands reductions in cause specific mortality are estimated. Nutrition interventions can impact either nutritional statuses or directly impact mortality. In the former case, LiST acts as a cohort model where current nutritional statuses such as stunting impact the probability of stunting as the cohort ages. LiST links with a demographic projections model (DemProj) to estimate the deaths and deaths averted due to the reductions in mortality rates. USING LIST: LiST can be downloaded at http://www.jhsph.edu/dept/ih/IIP/list/ where simple instructions are available for installation. LiST includes default values for coverage and effectiveness for many less developed countries obtained from credible sources. CONCLUSIONS: The development of LiST is a continuing process. Via technical inputs from the Child Health Epidemiological Group, effectiveness values are updated, interventions are adopted and new features added.

Quantifying the potential market for new contraceptive technologies: global projections of 2040 contraceptive needs and preferences.

Background: Despite a wide range of contraceptive methods, unmet need persists. New contraceptive technologies (CTs) have the potential to improve uptake and continuation. CT development has a long-time horizon; products will be introduced into markets that look very different than today. Identifying viable investments requires an understanding of these future markets. For this work the 2040 potential contraceptive market is described utilizing seven market segments based on marital status, fertility preferences, and patterns of sexual activity outside of marriage.  Methods: Market size estimates are developed by country for all countries in the world for a current market (2020) and a future market (2040). United Nation's (UN) population projections of the number of women of reproductive age (WRA) form the basis of this work. WRA are then segmented into market segments based on marital status, fertility intentions, and patterns of sexual activity outside of marriage.  Each segment is further subdivided by contraceptive use versus non-use.  Segmentation draws from UN projections, household surveys, census data, and modeling techniques developed for this work. Results: The largest market increases will be seen in Africa; most notably among the segment of married women wanting no more children. By contrast, Asia will see declines across all three married segments, coupled with increases among sexually active unmarried segments.  Levels of contraceptive use are projected to vary widely by segment, with differential patters across regions. Conclusions: This analysis projects the impact of demographic changes, evolving fertility preferences, shifts in sexual activity outside of marriage and increased utilization of contraceptives in shaping the contraceptive market of 2040. Results show that there is not one global market, but distinct markets that vary in size and shape across the world. This diversity suggests that a range of different new CTs could have potential for uptake.

Cost and impact of scaling up female genital mutilation prevention and care programs: Estimated resource requirements and impact on incidence and prevalence.

PURPOSE: SDG 5.3 targets include eliminating harmful practices such as Female Genital Mutilation (FGM). Limited information is available about levels of investment needed and realistic estimates of potential incidence change. In this work, we estimate the cost and impact of FGM programs in 31 high burden countries. METHODS: This analysis combines program data, secondary data analysis, and population-level costing methods to estimate cost and impact of high and moderate scaleup of FGM programs between 2020 and 2030. Cost per person or community reached was multiplied by populations to estimate costs, and regression analysis was used to estimate new incidence rates, which were applied to populations to estimate cases averted. RESULTS: Reaching the high-coverage targets for 31 countries by 2030 would require an investment of US$ 3.3 billion. This scenario would avert more than 24 million cases of FGM, at an average cost of US$ 134 per case averted. A moderate-coverage scenario would cost US$ 1.6 billion and avert more than 12 million cases of FGM. However, average cost per case averted hides substantial variation based on country dynamics. The most cost-effective investment would be in countries with limited historic change in FGM incidence, with the average cost per case averted between US$ 3 and US$ 90. The next most effective would be those with high approval for FGM, but a preexisting trend downward, where cost per case averted is estimated at around US$ 240. INTERPRETATION: This analysis shows that although data on FGM is limited, we can draw useful findings from population-level surveys and program data to guide resource mobilization and program planning.

Applying the Community Health Worker Coverage and Capacity Tool for Time-Use Modeling for Program Planning in Rwanda and Zanzibar.

Community health worker (CHW) programs are a critical component of health systems, notably in lower- and middle-income countries. However, when policy recommendations exceed what is feasible to implement, CHWs are overstretched by the volume of activities, implementation strength is diluted, and programs fail to produce promised outcomes. To counteract this, we developed a time-use modeling tool-the CHW Coverage and Capacity (C3) Tool-and used it with government partners in Rwanda and Zanzibar to address common policy questions related to CHW needs, coverage, and time optimization.In Rwanda, the C3 Tool was used to analyze 2 well-established cadres of CHWs and 1 new one. The well-established CHW cadres were within a "manageable" workload range whereas the new cadre was projected to achieve less than half of assigned activities. This is informing ongoing changes to the CHWs' scopes of work. In Zanzibar, the C3 Tool was used to update the national community health strategy to include community health volunteers (CHVs) for the first time and determine how many CHVs were needed. The tool projected that 2,200 CHVs could achieve approximately 90% coverage of all defined services. Based on these figures, Zanzibar updated its national community health strategy, which officially launched in February 2020.We discuss lessons from these 2 experiences. Translating analysis into decision making depends not only on the programmatic will and motivation of governments but also on finding opportune timing for when policy and program processes allow for optimization of CHW investments. Further research is needed but our experience supports the value of a modeling tool to ground program plans within estimated constraints on CHW time.

Who is the vulnerable child? Using survey data to identify children at risk in the era of HIV and AIDS.

Over the past decade, there has been increasing global attention to mitigating the impacts of the HIV/AIDS epidemic on children's lives. Within this context, developing and tracking global child vulnerability indicators in relation to HIV and AIDS has been critical in terms of assessing need and monitoring progress. Although orphanhood and adult household illness (co-residence with a chronically ill or HIV-positive adult) are frequently used as markers, or definitions, of vulnerability for children affected by HIV and AIDS, evidence supporting their effectiveness has been equivocal. Data from 60 nationally representative household surveys (36 countries) were analyzed using bivariate and multivariate methods to establish if these markers consistently identified children with worse outcomes and also to identify other factors associated with adverse outcomes for children. Outcome measures utilized were wasting among children aged 0-4 years, school attendance among children aged 10-14 years, and early sexual debut among adolescent boys and girls aged 15-17 years. Results indicate that orphanhood and co-residence with a chronically ill or HIV-positive adult are not universally robust measures of child vulnerability across national and epidemic contexts. For wasting, early sexual debut, and to a lesser extent, school attendance, in the majority of surveys analyzed, there were few significant differences between orphans and non-orphans or children living with chronically ill or HIV-positive adults and children not living with chronically ill or HIV-positive adults. Of other factors analyzed, children living in households where the household head or eldest female had a primary education or higher were significantly more likely to be attending school, better household health and sanitation was significantly associated with less wasting, and greater household wealth was significantly associated both with less wasting and better school attendance. Of all marker of child vulnerability analyzed, only household wealth consistently showed power to differentiate across age-disaggregated outcomes. Overall, the findings indicate the need for a multivalent approach to defining child vulnerability, one which incorporates household wealth as a key predictor of child vulnerability.

Return to sexual activity and modern family planning use in the extended postpartum period: an analysis of findings from seventeen countries.

Unintended pregnancies can lead to poor maternal and child health outcomes. Family planning use during the first year postpartum has the potential to significantly reduce at least some of these unintended pregnancies. This paper examines the relationship of menses return, breastfeeding status, and postpartum duration on return to sexual activity and use of modern family planning among postpartum women. This paper presents results from a secondary data analysis of Demographic and Health Surveys from 17 countries. For postpartum women, the return of menses, breastfeeding status, and postpartum duration are significantly associated with return to sexual activity in at least 10 out of the 17 countries but not consistently associated with family planning use. Only menses return had a significant association with use of modern family planning in the majority of countries. These findings point to the importance of education about pregnancy risk prior to menses return.

Patterns and trends of postpartum family planning in Ethiopia, Malawi, and Nigeria: evidence of missed opportunities for integration.

BACKGROUND: The first 12 months following childbirth are a period when a subsequent pregnancy holds the greatest risk for mother and baby, but also when there are numerous contacts with the healthcare system for postnatal care for mother and baby (immunisation, nutrition, etc.). The benefits and importance of postpartum family planning are well documented. They include a reduction in risk of miscarriage, as well as mitigation of (or protection against) low birth weight, neonatal and maternal death, preterm birth, and anaemia. OBJECTIVES: The objectives of this paper are to assess patterns and trends in the use of postpartum family planning at the country level, to determine whether postpartum family planning is associated with birth interval and parity, and to identify the health services most closely associated with postpartum family planning after adjusting for socio-economic characteristics. DESIGN: Data were used from Demographic and Health Surveys that contain a reproductive calendar, carried out within the last 10 years, from Ethiopia, Malawi, and Nigeria. All women for whom the calendar was completed and who gave birth between 57 and 60 months prior to data collection were included in the analysis. For each of the births, we merged the reproductive calendar with the birth record into a survey for each country reflecting the previous 60 months. The definition of the postpartum period in this paper is based on a period of 3 months postpartum. We used this definition to assess early adoption of postpartum family planning. We assessed variations in postpartum family planning according to demographic and socio-economic variables, as well as its association with various contact opportunities with the health system [antenatal care (ANC), childbirth in facilities, immunisation, etc.]. We did simple descriptive analysis with tabular, graphic, and 'equiplot' displays and a logistic regression controlling for important background characteristics. RESULTS: Overall, variation in postpartum use of modern contraception was not affected over the years by age or marital status. One contrast to this is in Ethiopia, where the data show a significant increase in uptake of postpartum contraception among adolescents from 2005 to 2011. There are systematic and pervasive equity issues in the use of modern postpartum family planning by education level, place of residence, and wealth quintile, especially in Ethiopia where the gaps are very large. Disaggregation of data also point to significant sub-national variations. After adjusting for socio-economic variables, the most consistent health sector services associated with modern postpartum contraception are institutional childbirth and child immunisation. ANC is less likely to be associated with the use of modern postpartum family planning. CONCLUSION: Postpartum use of modern family planning has remained very low over the years, including for childbearing adolescents. Our results indicate that improving postpartum family planning requires policies and strategies to address the inequalities caused by socio-economic factors and the integration of family planning with maternal and newborn health services, particularly with childbirth in facilities and child immunisation. Scaling up systematic screening, training of providers, and generation of demand are some possible ways forward.

New findings for maternal mortality age patterns: aggregated results for 38 countries.

BACKGROUND: With recent results showing a global decline in overall maternal mortality during the last two decades and with the target date for achieving the Millennium Development Goals only four years away, the question of how to continue or even accelerate the decline has become more pressing. By knowing where the risk is highest as well as where the numbers of deaths are greatest, it may be possible to re-direct resources and fine-tune strategies for greater effectiveness in efforts to reduce maternal mortality. METHODS: We aggregate data from 38 Demographic and Health Surveys that included a maternal mortality module and were conducted in 2000 or later to produce maternal mortality ratios, rates, and numbers of deaths by five year age groups, separately by residence, region, and overall mortality level. FINDINGS: The age pattern of maternal mortality is broadly similar across regions, type of place of residence, and overall level of maternal mortality. A "J" shaped curve, with markedly higher risk after age 30, is evident in all groups. We find that the excess risk among adolescents is of a much lower magnitude than is generally assumed. The oldest age groups appear to be especially resistant to change. We also find evidence of extremely elevated risk among older mothers in countries with high levels of HIV prevalence. CONCLUSIONS: The largest number of deaths occurs in the age groups from 20-34, largely because those are the ages at which women are most likely to give birth so efforts directed at this group would most effectively reduce the number of deaths. Yet equity considerations suggest that efforts also be directed toward those most at risk, i.e., older women and adolescents. Because women are at risk each time they become pregnant, fulfilling the substantial unmet need for contraception is a cross-cutting strategy that can address both effectiveness and equity concerns.

Effects of aluminum oxide nanoparticles on the growth, development, and microRNA expression of tobacco (Nicotiana tabacum).

Nanoparticles are a class of newly emerging environmental pollutions. To date, few experiments have been conducted to investigate the effect nanoparticles may have on plant growth and development. It is important to study the effects nanoparticles have on plants because they are stationary organisms that cannot move away from environmental stresses like animals can, therefore they must overcome these stresses by molecular routes such as altering gene expression. microRNAs (miRNA) are a newly discovered, endogenous class of post-transcriptional gene regulators that function to alter gene expression by either targeting mRNAs for degradation or inhibiting mRNAs translating into proteins. miRNAs have been shown to mediate abiotic stress responses such as drought and salinity in plants by altering gene expression, however no study has been performed on the effect of nanoparticles on the miRNA expression profile; therefore our aim in this study was to classify if certain miRNAs play a role in plant response to Al(2)O(3) nanoparticle stress. In this study, we exposed tobacco (Nicotiana tabacum) plants (an important cash crop as well as a model organism) to 0%, 0.1%, 0.5%, and 1% Al(2)O(3) nanoparticles and found that as exposure to the nanoparticles increased, the average root length, the average biomass, and the leaf count of the seedlings significantly decreased. We also found that miR395, miR397, miR398, and miR399 showed an extreme increase in expression during exposure to 1% Al(2)O(3) nanoparticles as compared to the other treatments and the control, therefore these miRNAs may play a key role in mediating plant stress responses to nanoparticle stress in the environment. The results of this study show that Al(2)O(3) nanoparticles have a negative effect on the growth and development of tobacco seedlings and that miRNAs may play a role in the ability of plants to withstand stress to Al(2)O(3) nanoparticles in the environment.

Factors related to induced abortion among young women in Edo State, Nigeria.

Sub-Saharan Africa has the highest death rate from induced abortion in the world, and young women in southern Nigeria are particularly likely to terminate their pregnancies. This study assesses the prevalence of and factors associated with induced abortion among 602 young women aged 15-24 who were surveyed in Edo State, Nigeria, in 2002. We find that 41 percent of all pregnancies reported by the young women surveyed were terminated, and we estimate the age-specific abortion rate for 15-19-year-olds in Edo State at 49 abortions per 1,000 women, which is slightly higher than previous local estimates and nearly double the countrywide estimate for women aged 15-49. We construct explanatory multivariate models to predict the likelihood that a young woman has experienced sexual intercourse, has become pregnant, and has undergone an induced abortion, controlling for important demographic and risk-behavior factors. Young women unmarried at the time of the interview are found to be significantly more likely than married women to have had an abortion. Young women who have experienced transactional or forced sex are also significantly more likely to report ever having had an abortion, as are young women who have experienced more than one pregnancy. We conclude with suggestions for modifying the content and target populations of behavioral change messages and programs in the area.