Not all inequalities are equal: differences in coverage across the continuum of reproductive health services.

Reducing inequalities in health service coverage is central to achieving the larger goal of universal health coverage. Reproductive health services are part of evidence-based health interventions that comprise a minimum set of essential health interventions that all countries should be able to provide. This paper shows patterns in inequalities in three essential reproductive health services that span a continuum of care-contraceptive use, antenatal care during pregnancy and delivery at a health facility. We highlight coverage gaps and their impacts across geographical regions, key population subgroups and measures of inequality. We focus on reproductive age women (15-49 years) in 10 geographical regions in Africa, Asia and Latin America and the Caribbean. We examine inequalities by age (15-19, 20-24, 25-34 and 35-49 years), household wealth quintile, residence (rural or urban) and parity. Data on service coverage and the population in need are from 84 nationally representative surveys. Our results show that dominant inequalities in contraceptive coverage are varied, and include large disparities and impact by age group, compared with maternal health services, where inequalities are largest by economic status and urban-rural residence. Using multiple measures of inequality (relative, absolute and population impact) not only helps to show if there are consistent patterns in inequalities but also whether few or many different approaches are needed to reduce these inequalities and where resources could be prioritised to reach the largest number of people in need.

Setting Ambitious yet Achievable Targets Using Probabilistic Projections: Meeting Demand for Family Planning.

In 2015, governments adopted 17 internationally agreed goals to ensure progress and well-being in the economic, social, and environmental dimensions of sustainable development. These new goals present a challenge for countries to set empirical targets that are ambitious yet achievable and that can account for different starting points and rates of progress. We used probabilistic projections of family planning indicators, based on a global data set and Bayesian hierarchical modeling, to generate illustrative targets at the country level. Targets were defined as the percentage of demand for family planning satisfied with modern contraceptive methods where a country has at least a 10 percent chance of reaching the target by 2030. National targets for 2030 ranged from below 50 percent of demand satisfied with modern contraceptives (for three countries in Africa) to above 90 percent (for 41 countries from all major areas of the world). The probabilistic approach also identified countries for which a global fixed target value of 75 percent demand satisfied was either unambitious or has little chance of achievement. We present the web-based Family Planning Estimation Tool (FPET) enabling national decision makers to compute and assess targets for meeting family planning demand.

National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis.

BACKGROUND: Expansion of access to contraception and reduction of unmet need for family planning are key components to improve reproductive health, but scarce data and variability in data sources create difficulties in monitoring of progress for these outcomes. We estimated and projected indicators of contraceptive prevalence and unmet need for family planning from 1990 to 2015. METHODS: We obtained data from nationally representative surveys, for women aged 15-49 years who were married or in a union. Estimates were based on 930 observations of contraceptive prevalence between 1950 and 2011 from 194 countries or areas, and 306 observations of unmet need for family planning from 111 countries or areas. We used a Bayesian hierarchical model combined with country-specific time trends to yield estimates of these indicators and uncertainty assessments. The model accounted for differences by data source, sample population, and contraceptive methods included in the measure. FINDINGS: Worldwide, contraceptive prevalence increased from 54·8% (95% uncertainty interval 52·3-57·1) in 1990, to 63·3% (60·4-66·0) in 2010, and unmet need for family planning decreased from 15·4% (14·1-16·9) in 1990, to 12·3% (10·9-13·9) in 2010. Almost all subregions, except for those where contraceptive prevalence was already high in 1990, had an increase in contraceptive prevalence and a decrease in unmet need for family planning between 1990 and 2010, although the pace of change over time varied between countries and subregions. In 2010, 146 million (130-166 million) women worldwide aged 15-49 years who were married or in a union had an unmet need for family planning. The absolute number of married women who either use contraception or who have an unmet need for family planning is projected to grow from 900 million (876-922 million) in 2010 to 962 million (927-992 million) in 2015, and will increase in most developing countries. INTERPRETATION: Trends in contraceptive prevalence and unmet need for family planning, and the projected growth in the number of potential contraceptive users indicate that increased investment is necessary to meet demand for contraceptive methods and improve reproductive health worldwide. FUNDING: United Nations Population Division and National University of Singapore.

Social organization and the transition from direct to indirect consumption.

This paper presents a new theoretical framework for the study of environmental consumption at the micro-level by building on concepts from classical sociological theory and recent macro-level studies of the environment. The framework emphasizes the local community context as an important determinant of environmental consumption. We test this framework with unique micro-level data on consumption, household size, household affluence, and community context from Nepal, a setting in the midst of dramatic change in community organization, population size, and consumption behavior. The results of these tests are consistent with the hypothesis that local nonfamily organizations shift the consumption of environmental resources from direct to more indirect. We argue that the framework presented here is a useful early step toward more comprehensive micro-level models of environmental quality.

Role of parents in adolescent sexual activity and contraceptive use in four African countries.

CONTEXT: Parents have an influence on the sexual and reproductive health of adolescents, but evidence from Sub- Saharan Africa is limited. A better understanding of the relationship between different dimensions of parenting and recent sexual activity and contraceptive use is needed in the region. METHODS: Data were collected in 2004 in nationally representative surveys of 12-19-year-olds in Burkina Faso, Ghana, Malawi and Uganda. Bivariate analysis compared gender differences for two outcomes among unmarried 15-19-year-olds-having had sexual intercourse in the last 12 months and, among those who had had sex in this period, contraceptive use at last sex. Multivariate logistic regression analysis identified associations between these outcomes and coresidence with parents or parent figures, parental monitoring and parent-child communication. RESULTS: Unmarried adolescents reported moderate to high levels of parental monitoring and low levels of parent-child communication about sexual matters. In all countries, adolescent males who reported low monitoring were at elevated risk of having had sex in the last year (odds ratios, 2.4-5.4), as were their female counterparts in three of the countries (6.9-7.7). Communication with parents was positively associated with sexual activity among Malawian males and Ugandan females (2.2 and 1.5, respectively). Parental monitoring was not associated with contraceptive use at last sex, whereas parent-child communication was associated with such use among Ghanaian females (3.0) and among Ugandan adolescents of both genders (1.9-2.0). CONCLUSIONS: Programs to improve adolescent sexual and reproductive health should include dimensions of parental involvement that can strengthen the program's specific behavior change goals.

Unsafe abortion in Zambia.

In Zambia, because safe, legal abortion is inaccessible to many women, an unknown number of women each year resort to illegal abortions, many of which are performed under unsanitary and unsafe conditions. The death toll from these procedures is likely high, and almost all such deaths could be avoided if access to safe abortion were improved and unintended pregnancies were prevented.

Associations between premarital sex and leaving school in four sub-Saharan African countries.

With the spread of formal schooling in sub-Saharan Africa and delays in the age at marriage, a growing proportion of adolescents remain enrolled in school when they "come of age." As a consequence, more and more adolescents have to negotiate sexual maturation and sexual initiation in a vastly different context from that of prior generations. Using data from the 2004 National Survey of Adolescents conducted in Burkina Faso, Ghana, Malawi, and Uganda, we investigate the empirical association between premarital sex and leaving school among those who were enrolled in school at the outset of adolescence (age 12). Discrete-time logistic regression models show that, in general, girls are more likely than boys to leave school before completing secondary school, before completing primary school, and, among those completing primary school, before progressing to secondary school. Girls who complete primary school, however, do so at the same age as or a younger age than their male peers. Girls appear more vulnerable to leaving school once they engage in premarital sex. These findings can assist researchers, policymakers, program managers, and educators in understanding and addressing the challenges to educational attainment posed by the increasing proportion of school-aged adolescents engaging in premarital sex.

Unsafe abortion in Kenya.

Though pregnancy termination is highly restricted in Kenya, induced abortion remains common. Illegal abortion is often unsafe, putting women at risk of death or severe complications. In eastern Africa as a whole, an estimated 14% of all pregnancies end in abortion, and nearly one in five maternal deaths are due to unsafe abortion.

Prevalence and meanings of exchange of money or gifts for sex in unmarried adolescent sexual relationships in sub-Saharan Africa.

Using national survey data collected in 2004 in Burkina Faso, Ghana, Malawi, and Uganda with 12-19 year olds, we examine the prevalence of sex in exchange for money or gifts in the 12 months prior to the survey and its association with adolescents' social and economic vulnerability and condom use. Receiving something in exchange for sex is very common among sexually active, unmarried female adolescents and there are no significant differences by household economic status, orphan status, level of schooling completed or age difference between partners. Condom use at last sex in the 12 months prior to the survey is not associated with receiving gifts or money. Qualitative data based on focus group discussions and in-depth interviews collected in 2003 with adolescents suggest that receiving money or gifts for sex is not necessarily a coercive force, but rather can be a routine aspect of dating.

Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.

Adolescents' views of and preferences for sexual and reproductive health services highlight promising directions and persistent challenges in preventing pregnancy and HIV and treating sexually-transmitted infections (STIs) in this population. Results from nationally-representative surveys of 12-19 year-olds in Burkina Faso, Ghana, Malawi and Uganda in 2004 show that contraceptive and STI services and HIV testing are still under-utilized. A substantial proportion of sexually-active adolescents do not know of any source to obtain contraception or get STI treatment, and social-psychological reasons (e.g., embarrassment or fear) and financial cost remain common barriers to getting services. Adolescents' preferences are overwhelmingly for public clinics, with strongly positive perceptions of confidentiality, accessibility and cost. Some gender and country differences exist, yet overall females and males' views are similar. Results highlight the need to inform youth about sources, increase availability of government health facilities and improve youth's access to them, especially by reducing social barriers.

Sexual behavior, knowledge and information sources of very young adolescents in four sub-Saharan African countries.

Adolescents are a key target group for HIV and pregnancy prevention efforts, yet very little is known about the youngest adolescents: those under age 15. New survey data from 12-14 year olds in Burkina Faso, Ghana, Malawi and Uganda are used to describe their sexual activity, knowledge about HIV, STIs and pregnancy prevention, and sources of sexual and reproductive health information, including sex education in schools. Results show that very young adolescents are already beginning to be sexually active and many believe their close friends are sexually active. They have high levels of awareness but little in-depth knowledge about pregnancy and HIV prevention. Multiple information sources are used and preferred by very young adolescents. Given their needs for HIV, STI and pregnancy prevention information that is specific and practical and considering that the large majority are attending school in most countries in Sub-Saharan Africa, school-based sex education is a particularly promising avenue for reaching adolescents under age 15.