Continued use of the Standard Days Method.

OBJECTIVE: To examine the long-term effectiveness and continuation of the Standard Days Method (SDM)®, a fertility awareness-based method of family planning that identifies Days 8-19 (inclusive) of the cycle as the fertile window. On these days users avoid unprotected sexual intercourse to prevent pregnancy. The method works best for women with cycles that are usually in the range of 26-32 days, which is an important reason for method discontinuation in the first year of use. The authors determine if this continues to be an issue in the second and third years of method use. METHODS: Participants in an earlier efficacy study (478 women in three countries) and method introduction studies (1181 women in four countries) were followed for 2 years beyond the original 1-year study period, to determine their continued use of the method, intended and unintended pregnancies, and reasons for discontinuation. Life-tables were used to approximate typical use pregnancy rates. RESULTS: The method continues to be effective in the second and third years of use, and compares favourably to other user-directed family planning methods. Women with no more than two cycles outside the 26-32-day range within a year are likely to continue having cycles within this range. CONCLUSIONS: Women who complete the first year of SDM use are likely to continue to be able to use the method successfully and effectively. The method presents a viable longer-term option for women who prefer this approach to family planning.

Reconsidering childhood undernutrition: can birth spacing make a difference? An analysis of the 2002-2003 El Salvador National Family Health Survey.

It is well understood that undernutrition underpins much of child morbidity and mortality in less developed countries, but the causes of undernutrition are complex and interrelated, requiring a multipronged approach for intervention. This paper uses a subsample of 3853 children under age 5 from the most recent family health survey in El Salvador to examine the relationship between birth spacing and childhood undernutrition (stunting and underweight). While recent research and guidance suggest that birth spacing of three to five years contributes to lower levels of infant and childhood mortality, little attention has been given to the possibility that short birth intervals have longer-term effects on childhood nutrition status. The analysis controls for clustering effects arising from siblings being included in the subsample, as well as variables that are associated with household resources, household structure, reproductive history and outcomes, and household social environment. The results of the multiple regression analyses find that in comparison to intervals of 36-59 months, birth intervals of less than 24 months and intervals of 24-35 months significantly increase the odds of stunting (<24 months Odds Ratio (OR) = 1.52; 95% confidence interval (CI): 1.21-1.92; 25-36 months OR = 1.30; 95% CI: 1.05-1.64). Other factors related to stunting and underweight include standard of living index quintile, child's age, mother's education, low birthweight, use of prenatal care, and region of the country where the child lives. Policy and program implications include more effective use of health services and outreach programs to counsel mothers on family planning, breastfeeding, and well child care.

Being strategic about contraceptive introduction: the experience of the Standard Days Method.

BACKGROUND: Many national and institutional family planning policies explicitly include fertility awareness-based methods among the method options that should be made available, but these methods are often not offered for a variety of reasons. After testing the efficacy of the Standard Days Method (SDM), which is a fertility awareness-based method that identifies Days 8-19 of the menstrual cycle as fertile for women with cycles lasting between 26 and 32 days, pilot studies were conducted to introduce it into programs. STUDY DESIGN: Through 14 pilot studies around the world, ministries of health, family planning associations and community development organizations introduced the SDM. Follow-up interviews with users and other data collection methodologies were used to track user characteristics and experiences. Supervision data and simulated clients assessed the effects on service delivery. RESULTS: The SDM appeals to a broad range of women throughout the world. Clients report using abstinence or condoms to manage the fertile days. Both men and women report high levels of satisfaction with the method. The cross-study first-year failure rate of 14.1 pregnancies per 100 woman-years of use is similar to typical-use rates found in the SDM efficacy trial. CONCLUSIONS: The results of the pilot studies offer guidance for scaling up service delivery of the SDM. Condom counseling can help many users manage the fertile window effectively. Because out-of-range cycles can lead to method failure, users must understand the importance of tracking cycle length and be willing to switch to another method when the SDM is contraindicated. Community providers can offer the method; within clinical settings, SDM counseling typically takes no more time than allowed in most program norms. Training providers to address alcohol use and gender-based violence improves SDM method use and contributes to better quality of care.

Partnerships for Policy Development: A Case Study From Uganda's Costed Implementation Plan for Family Planning.

In global health, partnerships between practitioners and policy makers facilitate stakeholders in jointly addressing those issues that require multiple perspectives for developing, implementing, and evaluating plans, strategies, and programs. For family planning, costed implementation plans (CIPs) are developed through a strategic government-led consultative process that results in a detailed plan for program activities and an estimate of the funding required to achieve an established set of goals. Since 2009, many countries have developed CIPs. Conventionally, the CIP approach has not been defined with partnerships as a focal point; nevertheless, cooperation between key stakeholders is vital to CIP development and execution. Uganda launched a CIP in November 2014, thus providing an opportunity to examine the process through a partnership lens. This article describes Uganda's CIP development process in detail, grounded in a framework for assessing partnerships, and provides the findings from 22 key informant interviews. Findings reveal strengths in Uganda's CIP development process, such as willingness to adapt and strong senior management support. However, the evaluation also highlighted challenges, including district health officers (DHOs), who are a key group of implementers, feeling excluded from the development process. There was also a lack of planning around long-term partnership practices that could help address anticipated execution challenges. The authors recommend that future CIP development efforts use a long-term partnership strategy that fosters accountability by encompassing both the short-term goal of developing the CIP and the longer-term goal of achieving the CIP objectives. Although this study focused on Uganda's CIP for family planning, its lessons have implications for any policy or strategy development efforts that require multiple stakeholders to ensure successful execution.

Is Household Wealth Associated With Use of Long-Acting Reversible and Permanent Methods of Contraception? A Multi-Country Analysis.

As programs continue to expand access to family planning information, services, and products, it is critical that these efforts be undertaken with an equity lens, ensuring that regardless of socioeconomic status, all women and couples can use the method that meets their needs. This study explores the relationship between household wealth and the use of long-acting and permanent methods (LAPMs) versus short-acting methods of contraception among modern method users, using multivariate analyses based on Demographic Health Survey data from 30 developing countries conducted between 2006 and 2013. Overall, and controlling for relevant individual and household characteristics including age, number of living children, education, and urban/rural residence, we found that wealthier women were more likely than poorer women to use LAPMs instead of short-acting methods: 20 of the 30 countries showed a positive and statistically significant association between wealth and LAPM use. For 10 of those countries, however, LAPM use was significantly higher only for the top (1 or 2) wealthiest quintiles. Eight countries showed no broad pattern of association, while in 2 countries-Bangladesh and India-poorer women were more likely to use LAPMs than wealthier women. The positive association between wealth and LAPM use was found most consistently in the Latin American and the Caribbean countries in our sample. These findings can help program implementers respond better to women's needs for modern contraception, especially in reaching women from lower- and middle-income households.

Regional trends in the use of short-acting and long-acting contraception accessed through the private and public sectors.

OBJECTIVE: To examine trends in the source of modern contraception (public versus private sector); method choice (long-acting or permanent methods versus short-acting methods); and method and source combined. METHODS: A retrospective analysis was conducted using data collected by national Demographic and Health Surveys and Reproductive Health Surveys during the period 1992-2012. The dataset included 18 low-income countries in Sub-Saharan Africa, 10 from Latin America and the Caribbean (LAC), and 8 from Asia. RESULTS: A substantial proportion-between 40% and 49%-of modern contraceptive users relied on the private sector in Asia and LAC in the last 20years, yet the proportion has been smaller in Sub-Saharan Africa, between 27% and 30%. Increased use of short-acting methods from both public and private sectors has driven the rise in contraceptive prevalence in Asia and LAC. Similarly, increased contraceptive prevalence in Sub-Saharan Africa reflected the increased use of short-acting methods obtained mainly through the public sector, with only limited use of long-acting or permanent methods through the private sector. CONCLUSION: The private sector has played a key role in the increase of modern CPR and the provision of modern contraceptives around the world, providing almost half of them in low-income countries. Yet, such increase was driven primarily by a more substantial role in the provision of short-acting methods than long acting and permanent methods.

Mind the gap: responding to the global funding crisis in family planning.

The widening gap between the cost of meeting family planning needs and the funding available for commodities and programmes is a concern among policymakers and reproductive health professionals. The gap could reach US dollars 210 million by 2015. Its causes are clear; its solutions are not. While changes in programme method mix and cost shifting could address this gap, an often-overlooked alternative is the development and introduction of effective, low-cost methods. The Standard Days Method (SDM) has a first-year failure rate of only 4.8 (correct use) and is acceptable to many women around the world. It is easily integrated into programmes. Many SDM users rely on CycleBeads to help identify the days when pregnancy is likely. Though already meeting couples' needs in many places, the SDM responds in a unique way to needs in settings with high use of traditional methods, high levels of unmet need, and chronic depletion of commodities. The donor gap could have negative consequences, but it also facilitates reassessing family planning programme policies to include other effective, low-cost methods.

Creating options in family planning for the private sector in Latin America.

The countries of Latin America and the Caribbean are facing the gradual phase-out of international-donor support of contraceptive commodities and technical and management assistance, as well as an increased reliance on limited public sector resources and a limited private sector role in providing contraceptives to the public. Therefore, those nations must develop multisectoral strategies to achieve contraceptive security. The countries need to consider information about the market for family planning commodities and services in order to define and promote complementary roles for the public sector, the commercial sector, and the nongovernmental-organization sector, as well as to better identify which segments of the population each of those sectors should serve. While it is unable to mandate private sector participation, the public sector can create conditions that support and promote a greater role for the private sector in meeting the growing needs of family planning users. Taking steps to actively involve and expand the private sector's market share is a critical strategy for achieving a more equitable distribution of available resources, addressing unmet need, and creating a more sustainable future for family planning commodities and services. This paper also discusses in detail the experiences of two countries, Paraguay and Peru. Paraguay's family planning market illustrates a vibrant private sector, but with limited access to family planning commodities and services for those who cannot afford private sector prices. In Peru a 1995 policy change that sought to increase family planning coverage had the effect of restricting access for the poor and leaving the Ministry of Health unable to pay for the growing need for family planning commodities and services.

Cultivating men's interest in family planning in rural El Salvador.

A pilot project in rural El Salvador tested the integration of family planning into a water and sanitation program as a strategy for increasing male involvement in family planning decison making and use. The organizations involved posited that integrating family planning into a resource management and community development project would facilitate male involvement by diffusing information, by referring men and women to services, and by expanding method choice to include the new Standard Days Method through networks established around issues men cared about and were already involved in. This article examines data from a community-based household survey to assess the impact of the intervention and finds significant changes in contraceptive knowledge, attitudes, and behavior from baseline to endline. Because the differences between baseline and endline are greater than the differences between participants and nonparticipants at endline, the study demonstrates the power of informal networks for spreading information.

Measuring AIDS-Related Behaviors in Older Populations: Methodological Issues.

Because of a dearth of research on reporting biases in the measurement of HIV-related sexual and drug use behaviors in older populations, it is frequently assumed that methodological findings of research conducted with younger populations will generalize to older respondents. In this study, estimates of the effect of the experimental manipulation of interview mode (interviewer administered vs. self-administered) were derived separately for three age strata: 12 to 49, 50 to 64, and 65+. Results of these analyses indicate that there were a number of noteworthy reversals in which interviewer-administered questioning in the older age strata produced higher esti-mates of the prevalence of substance use or alcohol-related problem behaviors. These results suggest that caution should be exercised in making generalizations from studies of reporting bias for HIV-related behaviors to older populations.

Automating Telephone Surveys: Using T-ACASI to Obtain Data on Sensitive Topics.

This paper describes a new interview data collection system that uses a personal computer equipped with a telephone interface card. This system, telephone audio computer-assisted self-interviewing or T-ACASI, offers the economy of telephone interviews while providing the privacy of self-administered questionnaires. We describe T-ACASI design considerations and operational characteristics. In addition, we present data from recent studies indicating that the T-ACASI system is stable, robust, and suitable for administering relatively long and complex questionnaires on sensitive topics, including drug use and sexual behaviors associated with HIV and other STDs.

Interview Mode and Measurement of Sexual Behaviors: Methodological Issues.

Studies of sexual and other sensitive behaviors are often fraught with a variety of reporting biases. When IAQs are used to collect data, respondents may underreport certain sensitive behaviors and overreport normative behaviors. SAQs can also pose problems: requiring that respondents be literate and able to follow skip patterns. In recent years, the development of computerized technologies--audio-CASI and T-ACASI--have begun to overcome some of the limitations of IAQs and SAQs. By providing a more private mode for data collection and standardized delivery of all questions, as well as automated skip patterns and range checks, audio-CASI and T-ACASI have been tested in a number of studies and found to be an effective way of reducing response bias, and thus, contributing to a better understanding of the prevalence and patterns of sexual and other sensitive behaviors.

Untreated gonococcal and chlamydial infection in a probability sample of adults.

CONTEXT: The prevalence and distribution of gonococcal and chlamydial infections in the general population are poorly understood. Development of nucleic acid amplification tests, such as the ligase chain reaction assay, provides new opportunities to estimate the prevalence of untreated infections in the population. OBJECTIVE: To estimate the overall prevalence of untreated gonococcal and chlamydial infections and to describe patterns of infection within specific demographic subgroups of the young adult population in Baltimore, Md. DESIGN AND SETTING: Cross-sectional behavioral survey based on a probability sample of Baltimore households with collection of urine specimens between January 1997 and September 1998. PARTICIPANTS: A total of 728 adults aged 18 to 35 years completed the interview portion of the study, and 579 of these respondents also provided a urine specimen adequate for testing. MAIN OUTCOME MEASURE: Prevalence of untreated infection, as measured by the percentage of specimens testing positive for gonococcal and chlamydial infection by ligase chain reaction, weighted to reflect variations in probabilities of sample selection from the population. Alternate estimates of the prevalence of recent treated infection were derived from clinically diagnosed cases reported to the Baltimore City Health Department and by diagnoses reported by participants in the survey. RESULTS: An estimated 5.3% (SE, 1.4%) of the population aged 18 to 35 years has an untreated gonococcal infection, and 3.0% (SE, 0.8%) is estimated to have an untreated chlamydial infection. While 7.9% (SE, 1.6%) of the population is estimated to have either an untreated gonococcal or chlamydial infection, estimated prevalence is substantially higher among black women (15.0%; SE, 3.7%). Few participants with untreated infections reported dysuria or discharge during the 6 months preceding testing. The estimated number of untreated gonococcal infections in the population (9241; SE, 2441) substantially exceeds both the number of such infections diagnosed among Baltimore adults aged 18 to 35 years and reported to the Baltimore City Health Department during 1998 (4566), and the estimated number of diagnoses derived using participants' reports for the 12 months prior to the survey (4708 [SE, 1918] to 5231 [SE, 2092]). The estimated number of untreated chlamydial infections (5231; SE, 1395) is also greater than the number of cases reported to the health department in 1998 (3664) but is slightly less than the estimated number of diagnoses derived using participants' reports of chlamydial infections diagnosed during the 12 months prior to the survey (5580 [SE, 1918] to 6975 [SE, 2441]). CONCLUSION: In 1997-1998, the estimated number of undiagnosed gonococcal and chlamydial infections prevalent in the population of Baltimore adults aged 18 to 35 years approached or exceeded the number of infections that were diagnosed and treated annually.

Creating options in family planning for the private sector in Latin America

Los países de América Latina y el Caribe enfrentan el cese gradual del apoyo y de la ayuda técnica y administrativa brindados por donantes internacionales a los proveedores de productos anticonceptivos, por lo que dependen cada vez más de los limitados recursos del sector público y del papel menguante del sector privado para la provisión de anticonceptivos al público en general. Así las cosas, dichos países tendrán que crear estrategias multisectoriales para lograr la provisión segura de anticonceptivos. Deberán, asimismo, tener en cuenta la situación del mercado de los productos y servicios de planificación familiar a fin de poder definir y promover los papeles complementarios que han de desempeñar el sector público, el sector comercial y el sector de las organizaciones no gubernamentales, así como determinar con más exactitud a qué grupos de la población debe servir cada uno de estos sectores. Si bien es cierto que el sector público no puede exigirle al sector privado su participación, sí le es posible crear las condiciones propicias para que este asuma un papel más destacado en la satisfacción de las necesidades cada vez mayores de quienes usan métodos de planificación familiar. Tomar medidas para incrementar la participación del sector privado en el mercado es una estrategia esencial si se ha de lograr una distribución más equitativa de los recursos existentes, satisfacer necesidades insatisfechas y crear un futuro sustentable para los proveedores de productos y servicios de planificación familiar. En este trabajo también se examinan en detalle las experiencias de dos países, Paraguay y Perú. El mercado de servicios de planificación familiar en Paraguay es ejemplo de la vigorosa participación del sector privado, aunque el acceso a los servicios de planificación familiar es limitado para quienes no pueden afrontar los costos de dicho sector. En Perú tuvo lugar en 1995 un cambio de políticas orientado a aumentar la cobertura de los servicios de planificación familiar que redundó en un acceso restringido para los pobres y dejó al Ministerio de Salud sin poder sufragar la necesidad creciente de productos y servicios de planificación familiar.