Impact of the Urban Reproductive Health Initiative on family planning uptake at facilities in Kenya, Nigeria, and Senegal.

BACKGROUND: The 2012 London Summit on Family Planning set ambitious goals to enable 120 million more women and adolescent girls to use modern contraceptives by 2020. The Urban Reproductive Health Initiative (URHI) was a Bill & Melinda Gates Foundation funded program designed to help contribute to these goals in urban areas in India, Kenya, Nigeria, and Senegal. URHI implemented a range of country-specific demand and supply side interventions, with supply interventions generally focused on improved service quality, provider training, outreach to patients, and commodity stock management. This study uses data collected by the Measurement, Learning & Evaluation (MLE) Project to examine the effectiveness of these supply-side interventions by considering URHI's influence on the number of family planning clients at health facilities over a four-year period in Kenya, Nigeria, and Senegal. METHODS: The analysis used facility audits and provider surveys. Principal-components analysis was used to create country-specific program exposure variables for health facilities. Fixed-effects regression was used to determine whether family planning uptake increased at facilities with higher exposure. Outcomes of interest were the number of new family planning acceptors and the total number of family planning clients per reproductive health care provider in the last year. RESULTS: Higher program component scores were associated with an increase in new family planning acceptors per provider in Kenya (ß = 18, 95% CI = 7-29), Nigeria (ß = 14, 95% CI = 8-20), and Senegal (ß = 7, 95% CI = 3-12). Higher scores were also associated with more family planning clients per provider in Kenya (ß = 31, 95% CI = 7-56) and Nigeria (ß = 26, 95% CI = 15-38), but not in Senegal. CONCLUSIONS: Supply-side interventions have increased the number of new family planning acceptors at facilities in urban Nigeria, Kenya, and Senegal and the overall number of clients in urban Nigeria and Kenya. While tailoring to the local environment, programs seeking to increase family planning use should include components to improve availability and quality of family planning services, which are part of a rights-based approach to family planning programming.

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.

Examination of youth sexual and reproductive health transitions in Nigeria and Kenya using longitudinal data.

BACKGROUND: The adolescent (ages 15-19) and young adult (ages 20-24) years are a crucial time as many sexual and reproductive health (SRH) transitions take place in these years. The study of youth SRH transitions in sub-Saharan Africa is limited due to a paucity of longitudinal data needed to examine the timing and circumstances of these transitions. METHODS: This paper uses recently collected longitudinal data from select urban areas in Kenya and Nigeria that include a large youth sample at baseline (2010/2011) and endline (2014). We control for unobserved heterogeneity in our modelling approach to correct for selectivity issues that are often ignored in similar types of analyses. RESULTS: We demonstrate that the transition patterns (i.e., sexual initiation, first marriage, and first pregnancy/birth) differ within and across the urban areas and countries studied. Urban Kenyan youth have more premarital sex and pregnancy than youth from the Nigerian cities. Further analyses demonstrate that more educated and wealthier youth transition later than their less educated and poorer counterparts. CONCLUSIONS: The findings from this study can be used to inform programs seeking to serve young people based on their varying reproductive health needs in different contexts over the adolescent and young adult years.

Contraceptive service provider imposed restrictions to contraceptive access in urban Nigeria.

BACKGROUND: Health service providers can restrict access to contraceptives through their own imposed biases about method appropriateness. In this study, provider biases toward contraceptive service provision among urban Nigerian providers was assessed. METHODS: Health providers working in health facilities, as well as pharmacists and patent medical vendors (PMV), in Abuja, Benin City, Ibadan, Ilorin, Kaduna, and Zaria, were surveyed in 2011 concerning their self-reported biases in service provision based on age, parity, and marital status. RESULTS: Minimum age bias was the most common bias while minimum parity was the least common bias reported by providers. Condoms were consistently provided with the least amount of bias, followed by provision of emergency contraception (EC), pills, injectables, and IUDs. Experience of in-service training for health facility providers was associated with decreased prevalence of marital status bias for the pill, injectable, and IUD; however, training experience did not, or had the opposite effect on, pharmacists and PMV operator's reports of service provision bias. CONCLUSIONS: Provider imposed eligibility barriers in urban study sites in Nigeria were pervasive - the most prevalent restriction across method and provider type was minimum age. Given the large and growing adolescent population - interventions aimed at increasing supportive provision of contraceptives to youth in this context are urgently needed. The results show that the effect of in-service training on provider biases was limited. Future efforts to address provider biases in contraceptive service provision, among all provider types, must find creative ways to address this critical barrier to increased contraceptive use.

Exposure to family planning messages and modern contraceptive use among men in urban Kenya, Nigeria, and Senegal: a cross-sectional study.

BACKGROUND: Family planning (FP) researchers and policy makers have often overlooked the importance of involving men in couples' fertility choices and contraception, despite the fact that male involvement is a vital factor in sexual and reproductive health programming. This study aimed to assess whether men's exposure to FP demand-generation activities is associated with their reported use of modern contraceptive methods. METHODS: We used evaluation data from the Measurement, Learning & Evaluation project for the Urban Reproductive Health Initiative (URHI) in select cities of three African countries (Kenya, Nigeria, and Senegal) collected in 2012/2013. A two-stage cluster sampling design was used to select a representative sample of men in the study sites. The sample for this study includes men aged 15-59 years who had no missing data on any of the key variables: 696 men in Kenya, 2311 in Nigeria, and 1613 in Senegal. We conducted descriptive analyses and multivariate logistic regression analyses to assess the associations of interest. All analyses were weighted to account for the study design and non-response rates using Stata version 13. RESULTS: The proportion of men who reported use of modern contraceptive methods was 58 % in Kenya, 43 % in Nigeria, and 27 % in Senegal. About 80 % were exposed to at least one URHI demand-generation activity in each country. Certain URHI demand-generation activities were significantly associated with men's reported use of modern contraception. In Kenya, those who participated in URHI-led community events had four times higher odds of reporting use of modern methods (aOR: 3.70; p < 0.05) while in Senegal, exposure to URHI-television programs (aOR: 1.40; p < 0.05) and having heard a religious leader speak favorably about FP (aOR: 1.72; p < 0.05) were associated with modern contraceptive method use. No such associations were observed in Nigeria. CONCLUSION: Study findings are important for informing future FP program activities that seek to engage men. Program activities should be tailored by geographic context as results from this study indicate city and country-level variations. These types of gender-comprehensive and context-specific programs are likely to be the most successful at reducing unmet need for FP.

The role of gender empowerment on reproductive health outcomes in urban Nigeria.

To date, limited evidence is available for urban populations in sub-Saharan Africa, specifically research into the association between urban women's empowerment and reproductive health outcomes. The objective of this study is to investigate whether women's empowerment in urban Nigerian settings is associated with family planning use and maternal health behaviors. Moreover, we examine whether different effects of empowerment exist by region of residence. This study uses baseline household survey data from the Measurement, Learning and Evaluation Project for the Nigerian Urban Reproductive Health Initiative being implemented in six major cities. We examine four dimensions of empowerment: economic freedom, attitudes towards domestic violence, partner prohibitions and decision-making. We determine if the empowerment dimensions have different effects on reproductive health outcomes by region of residence using multivariate analyses. Results indicate that more empowered women are more likely to use modern contraception, deliver in a health facility and have a skilled attendant at birth. These trends vary by empowerment dimension and by city/region in Nigeria. We conclude by discussing the implications of these findings on future programs seeking to improve reproductive health outcomes in urban Nigeria and beyond.

Unintended pregnancy: magnitude and correlates in six urban sites in Senegal.

BACKGROUND: In Senegal, unintended pregnancy has become a growing concern in public health circles. It has often been described through the press as a sensational subject with emphasis on the multiple infanticide cases as a main consequence, especially among young unmarried girls. Less scientific evidence is known on this topic, as fertility issues are rarely discussed within couples. In a context where urbanization is strong, economic insecurity is persistent and the population is globalizing, it is important to assess the magnitude of unintended pregnancy among urban women and to identify its main determinants. METHODS: Data were collected in 2011 from a representative sample of 9614 women aged 15-49 years in six urban sites in Senegal. For this analysis, we include 5769 women who have ever been pregnant or were pregnant at the time of the survey. These women were asked if their last pregnancy in the last two years was 'wanted 'then', 'wanted later' or 'not wanted'. Pregnancy was considered as unintended if the woman responded 'wanted later' or 'not wanted'. Descriptive analyses were performed to measure the magnitude of unintended pregnancies, while multinomial logistic regression models were used to identify factors associated with the occurrence of unintended pregnancy. The analyses were performed using Stata version 12. All results were weighted. RESULTS: The results show that 14.3% of ever pregnant women reported having a recent unintended pregnancy. The study demonstrates important distinctions between women whose last pregnancy was intended and those whose last pregnancy was unintended. Indeed, this last group is more likely to be poor, from a young age (< 25 years) and multiparous. In addition, it appears that low participation of married women in decision-making within the couple (management of financial resources) and the lack of discussion on family planning issues are associated with greater experience of unintended pregnancy. CONCLUSION: This study suggests a need to implement more targeted programs that guarantee access to family planning for all women in need. In urban areas that are characterized by economic insecurity, as in Senegal, it is important to consider strategies for promoting communication within couples on fertility issues.

Association of men's exposure to family planning programming and reported discussion with partner and family planning use: The case of urban Senegal.

BACKGROUND: Family planning programs increasingly aim to encourage men to be involved in women's reproductive health decision-making as well as support men to be active agents of change for their own and the couple's reproductive health needs. This study contributes to this area of work by examining men's exposure to family planning (FP) program activities in urban Senegal and determining whether exposure is associated with reported FP use and discussion of family planning with female partners. METHODS: This study uses data from two cross-sectional surveys of men in four urban sites of Senegal (Dakar, Pikine, Guédiawaye, Mbao). In 2011 and 2015, men ages 15-59 in a random sample of households from study clusters were approached and asked to participate in a survey about their fertility and family planning experiences. These data were used to determine the association between exposure to the Initiative Sénégalaise de Santé Urbaine (in English: Senegal Urban Reproductive Health Initiative) family planning program interventions with men's reported modern family planning use and their reported discussion of FP with their partners. Since data come from the same study clusters at each time period, fixed effects methods at the cluster level allowed us to control for possible program targeting by geographic area. RESULTS: Multivariate models demonstrate that religious leaders speaking favorably about family planning, seeing FP messages on the television, hearing FP messages on the radio, and exposure to community outreach activities with a FP focus (e.g., house to house and community religious dialogues) are associated with reported modern family planning use and discussion of family planning with partners among men in the four urban sites of Senegal. CONCLUSIONS: This study demonstrates that it is possible to reach men with FP program activities in urban Senegal and that these activities are positively associated with reported FP behaviors.

The Senegal urban reproductive health initiative: a longitudinal program impact evaluation.

OBJECTIVES: This paper presents the impact of key components of the Senegal Urban Reproductive Health Initiative, including radio, television, community-based activities, Muslim religious-leader engagement and service quality improvement on modern contraceptive use by all women and the sub-sample of poor women. STUDY DESIGN: This study uses baseline (2011) and endline (2015) longitudinal data from a representative sample of urban women first surveyed in 2011 to examine the impact of the Initiative's demand- and supply-side activities on modern contraceptive use. RESULTS: By endline, there was increased exposure to radio and television programming, religious leaders speaking favorably about contraception, and community-based initiatives. In the same period, modern contraceptive use increased from 16.9% to 22.1% with a slightly larger increase among the poor (16.6% to 24.1%). Multivariate analyses demonstrate that women exposed to community-based activities were more likely to use modern contraception by endline (marginal effect (ME): 5.12; 95% confidence interval (CI): 2.50-7.74) than those not exposed. Further, women living within 1 km of a facility with family planning guidelines were more likely to use (ME: 3.54; 95% CI: 1.88-5.20) than women without a nearby facility with guidelines. Among poor women, community-based activities, radio exposure (ME: 4.21; 95% CI: 0.49-7.93), and living close to program facilities (ME: 4.32; 95% CI: 0.04-8.59) impacted use. CONCLUSIONS: Community-based activities are important for reaching urban women, including poor women, to achieve increased contraceptive use. Radio programming is also an important tool for increasing demand, particularly among poor women. Impacts of other program activities on contraceptive use were modest. IMPLICATIONS: This study demonstrates that community-based activities led to increased modern contraceptive use among all women and poor women in urban Senegal. These findings can inform future programs in urban Senegal and elsewhere in francophone Africa.

Longitudinal Evaluation of the Tupange Urban Family Planning Program in Kenya.

CONTEXT: Levels of fertility and contraceptive use have long fluctuated in Kenya. The multicomponent Tupange program, part of the Urban Reproductive Health Initiative, was initiated in 2011 to increase use of modern family planning methods. METHODS: Women aged 15-49 in the five Kenyan cities where Tupange was implemented were interviewed in 2010 and reinterviewed in 2014 to obtain information on their contraceptive use and exposure to components of the Tupange program. Fixed-effects models were estimated to identify associations between program exposure and use of modern family planning methods. Analyses were performed to determine the relative cost-effectiveness of program components. RESULTS: During the four-year follow-up period, the proportion of women using modern contraceptives increased from 45% to 52%, and the proportion of users who were using long-acting or permanent methods rose from 6% to 19%. The fixed-effects model indicated that modern method use was associated with having heard Tupange-related local radio programming and marginally associated with having discussed family planning with a community health worker (CHW); among women who were unmarried or did not give birth during the study period, modern method use was associated with living near program facilities. Local radio programming was the most cost-effective program component, followed by proximity to Tupange facilities and discussions with CHWs. CONCLUSIONS: Urban reproductive health programs seeking to increase use of modern family planning methods in Kenya and other Sub-Saharan African settings should consider multicomponent approaches that include CHW activities, local radio programming and improvements to the supply environment.

Key Role of Drug Shops and Pharmacies for Family Planning in Urban Nigeria and Kenya.

BACKGROUND: The Family Planning 2020 initiative aims to reach 120 million new family planning users by 2020. Drug shops and pharmacies are important private-sector sources of contraception in many contexts but are less well understood than public-sector sources, especially in urban environments. This article explores the role that drug shops and pharmacies play in the provision of contraceptive methods in selected urban areas of Nigeria and Kenya as well as factors associated with women's choice of where to obtain these methods. METHODS: Using data collected in 2010/2011 from representative samples of women in selected urban areas of Nigeria and Kenya as well as a census of pharmacies and drug shops audited in 2011, we examine the role of drug shops and pharmacies in the provision of short-acting contraceptive methods and factors associated with a women's choice of family planning source. RESULTS: In urban Nigeria and Kenya, drug shops and pharmacies were the major source for the family planning methods of oral contraceptive pills, emergency contraceptives, and condoms. The majority of injectable users obtained their method from public facilities in both countries, but 14% of women in Nigeria and 6% in Kenya obtained injectables from drug shops or pharmacies. Harder-to-reach populations were the most likely to choose these outlets to obtain their short-acting methods. For example, among users of these methods in Nigeria, younger women (<25 years old) were significantly more likely to obtain their method from a drug shop or pharmacy than another type of facility. In both countries, family planning users who had never been married were significantly more likely than married users to obtain these methods from a drug shop or a pharmacy than from a public-sector health facility. Low levels of family planning-related training (57% of providers in Kenya and 41% in Nigeria had received training) and lack of family planning promotional activities in pharmacies and drug shops in both countries indicate the need for additional support from family planning programs to leverage this important access point. CONCLUSIONS: Drug shops and pharmacies offer an important and under-leveraged mechanism for expanding family planning access to women in urban Nigeria and Kenya, and potentially elsewhere. Vulnerable and harder-to-reach groups such as younger, unmarried women and women who do not yet have children are the most likely to benefit from increased access to family planning at drug shops and pharmacies.

Impact evaluation of the Urban Health Initiative in urban Uttar Pradesh, India.

OBJECTIVES: The Urban Health Initiative (UHI) was initiated in 2009 with the goal of increasing family planning (FP) use among the poor in urban areas of Uttar Pradesh, India. The Measurement, Learning & Evaluation project (MLE) was tasked with rigorous impact evaluation of the UHI. This paper presents the impact evaluation findings of the UHI program. STUDY DESIGN: The MLE design includes a longitudinal sample of women and health facilities with baseline (2010) and endline (2014) data collection in six cities in Uttar Pradesh, India. At baseline, samples representative of women in each city were selected with oversampling of the poor. Eighty-four percent of women interviewed at baseline were reinterviewed 4 years later at endline. The longitudinal data support a within/fixed-effects approach to identification of program impact on changes in modern FP use. RESULTS: Impact evaluation results show significant effects of exposure to both demand and supply side program activities. In particular, women exposed to brochures (marginal effect: 6.96, p<.001), billboards/posters/wall hangings (marginal effect: 2.09, p<.05), and FP on the television (marginal effect: 2.46, p<.001) were significantly more likely to be using a modern method at endline. In addition, we found borderline significance for being exposed to a community health worker (marginal effect: 1.66, p<.10) and living close to an improved public and private supply environment where UHI undertook activities (marginal effects and p values: 2.48, p<.05 and 1.56, p<.10, respectively). CONCLUSIONS: UHI program activities were designed to complement the Government of India's strategies aimed at ensuring access to and provision of FP to urban poor populations. The effective demand- and supply-side strategies of the UHI program are therefore likely to be sustainable and scalable to other urban areas in India. IMPLICATIONS STATEMENT: Findings from this study are important for designing sustainable and scalable FP strategies for urban India where increases in FP use will be relevant for meeting international FP targets.

Belief in Family Planning Myths at the Individual and Community Levels and Modern Contraceptive Use in Urban Africa.

CONTEXT: Negative myths and misconceptions about family planning are a barrier to modern contraceptive use. Most research on the subject has focused on individual beliefs about contraception; however, given that myths spread easily within communities, it is also important to examine how the prevalence of negative myths in a community affects the aggregate level of method use. METHODS: Baseline data collected in 2010-2011 by the Measurement, Learning & Evaluation project on women aged 15-49 living in selected cities in Kenya, Nigeria and Senegal were used. Multivariate analyses examined associations between modern contraceptive use and belief in negative myths for individuals and communities. RESULTS: In each country, the family planning myths most prevalent at the individual and community levels were that "people who use contraceptives end up with health problems," "contraceptives are dangerous to women's health" and "contraceptives can harm your womb." On average, women in Nigeria and Kenya believed 2.7 and 4.6 out of eight selected myths, respectively, and women in Senegal believed 2.6 out of seven. Women's individual-level belief in myths was negatively associated with their modern contraceptive use in all three countries (odds ratios, 0.2-0.7). In Nigeria, the women's community-level myth variable was positively associated with modern contraceptive use (1.6), whereas the men's community-level myth variable was negatively associated with use (0.6); neither community-level variable was associated with modern contraceptive use in Kenya or Senegal. CONCLUSION: Education programs are needed to dispel common myths and misconceptions about modern contraceptives. In Nigeria, programs that encourage community-level discussions may be effective at reducing myths and increasing modern contraceptive use.

Factors associated with contraceptive ideation among urban men in Nigeria.

OBJECTIVE: To determine factors influencing the readiness of urban Nigerian men to adopt contraceptive methods. METHODS: The data were derived from a cross-sectional household survey conducted in Ibadan and Kaduna between September and November 2012. The sample included 2358 men from both cities. An ideation framework was constructed and a multilevel analysis performed to identify factors associated with positive thinking about contraception. RESULTS: Correlates of ideation operated at the individual, household, and community levels. There is considerable cluster-level variability in ideation score. The key correlates included exposure to family planning promotion campaigns, education, age, religion, marital status, and community norms. Compared with no education, high education is associated with an approximately 6.7-point increase in ideation score (P<0.001). Men with a high level of NURHI program exposure had an average ideation score that was about 3.4 points higher than for their peers with no exposure (P<0.001). The ideation score for Muslims was lower by approximately 1.7 points, on average, than for Christians (P<0.001). CONCLUSION: A comprehensive strategy of communication and behavior change activities surrounding contraceptive use should be tailored to meet the needs of specific groups of men. Community-level interventions designed to mobilize community members and change social norms that hinder the spread of ideational characteristics that favor contraceptive use should be part of this comprehensive strategy.

Demand generation activities and modern contraceptive use in urban areas of four countries: a longitudinal evaluation.

Family planning is crucial for preventing unintended pregnancies and for improving maternal and child health and well-being. In urban areas where there are large inequities in family planning use, particularly among the urban poor, programs are needed to increase access to and use of contraception among those most in need. This paper presents the midterm evaluation findings of the Urban Reproductive Health Initiative (Urban RH Initiative) programs, funded by the Bill & Melinda Gates Foundation, that are being implemented in 4 countries: India (Uttar Pradesh), Kenya, Nigeria, and Senegal. Between 2010 and 2013, the Measurement, Learning & Evaluation (MLE) project collected baseline and 2-year longitudinal follow-up data from women in target study cities to examine the role of demand generation activities undertaken as part of the Urban RH Initiative programs. Evaluation results demonstrate that, in each country where it was measured, outreach by community health or family planning workers as well as local radio programs were significantly associated with increased use of modern contraceptive methods. In addition, in India and Nigeria, television programs had a significant effect on modern contraceptive use, and in Kenya and Nigeria, the program slogans and materials that were blanketed across the cities (eg, leaflets/brochures distributed at health clinics and the program logo placed on all forms of materials, from market umbrellas to health facility signs and television programs) were also significantly associated with modern method use. Our results show that targeted, multilevel demand generation activities can make an important contribution to increasing modern contraceptive use in urban areas and could impact Millennium Development Goals for improved maternal and child health and access to reproductive health for all.

Urban environment and health: food security.

The authors examine the impact of urbanization on food security and human health in the Middle East. Within-urban-population disparities in food security represent one of the most dramatic indicators of economic and health disparities. These disparities are reflected in a double burden of health outcomes: increasing levels of chronic disease as well as growing numbers of undernourished among the urban poor. These require further comprehensive solutions. Some of the factors leading to food insecurity are an overdependence on purchased food commodities, lack of sufficient livelihoods, rapid reductions in peripheral agricultural land, and adverse impacts of climate change. The Food and Agriculture Organization of the United Nations (FAO) Food Security Framework is used to examine and compare 2 cities in the Middle East: Amman, Jordan, and Manama, Bahrain.