Need for Standardized Measure of Modern Method Availability: Assessment of Indicators Using Health Facility Data from Three Country Contexts.

The concept of contraceptive method choice is complex and difficult to measure, usually requiring multiple metrics that represent the service environment, access, and acceptability. One of the most used measures for the family planning service delivery environment is method availability, or specifically, the contraceptive options that are available to clients at any given family planning service delivery point. Despite the importance of the measure, indicator definitions vary widely and are not standardized. We identified six versions of the method availability indicator and calculated each version using Service Provision Assessment data from three countries with varying family planning profiles, health service structures, and from different geographic areas: Bangladesh, the Democratic Republic of Congo, and Haiti. We compared method availability estimates by urban/rural location, facility type, and across country context. Our results showed a wide variability in method availability estimates depending on the indicator used. Generally, indicators requiring a particular mix of method types had lower estimates of method availability than indicators only requiring a minimum number of methods. Results are discussed and recommendations are made to standardize indicator language and guidance. We further recommend the standardization of an indicator with a minimum mix of method types to ensure that a variety of method preferences can be met.

Attitudes and Opinions of Young People in Mali on Family Planning, Barriers to Contraceptive Use, and Suggestions for Programming.

The purpose of the research was to investigate Malian youth's attitudes and opinions about Family Planning (FP), barriers to contraceptive use, and suggestions for FP programming. Qualitative data were collected in focus group discussions (FGD) held with 95 females and males ages 18-24 in the district towns of Kita, Kolokani, Mopti, Sikasso, and Tombouctou. Qualitative thematic content analysis techniques were used to analyze the data. Benefits of FP use were acknowledged; however, it was still considered a taboo topic, especially for unmarried youth. This makes it difficult for youth to access information and services. Many participants expressed a desire to learn more about FP, though they underscored the need for confidential and discrete services. Programming suggestions included improving access to information, raising community awareness, and improving access to methods. The study findings can be used to improve messaging, counseling, outreach, and communication, to improve youth's reproductive health in Mali.

Availability of family planning services and quality of counseling by faith-based organizations: a three country comparative analysis.

BACKGROUND: Faith-based organizations (FBOs) have a long history of providing health services in developing countries and are important contributors to healthcare systems. Support for the wellbeing of women, children, and families is evidenced through active participation in the field of family planning (FP). However, there is little quantitative evidence on the availability or quality of FP services by FBOs. METHODS: The descriptive analysis uses facility-level data collected through recent Service Provision Assessments in Malawi (2013-14), Kenya (2010), and Haiti (2012) to examine 11 indicators of FP service and method availability and nine indicators of comprehensive and quality counseling. The indicators include measures of FP service provision, method mix, method stock, the provision of accurate information, and the discussion of reproductive intentions, client's questions/concerns, prevention of sexually transmitted infections, and return visits, among others. Pearson's Chi-square test is used to assess the selected indicators by managing authority (FBO, public, and other private sector) to determine statistical equivalence. RESULTS: Results show that FBOs are less likely to offer FP services than other managing authorities (p < 0.05). For example, 69% of FBOs in Kenya offer FP services compared to 97% of public facilities and 83% of other private facilities. Offering long-acting or permanent methods in faith-based facilities is especially low (43% in Malawi, 29% in Kenya and 39% in Haiti). There were few statistically significant differences between the managing authorities in comprehensive and quality counseling indicators. Interestingly, Haitian FBOs often perform as well or better than public sector health facilities on counseling indicators, such as discussion of a return visit (79% of FBO providers vs. 68% of public sector providers) and discussion of client concerns/questions (52% vs. 49%, respectively). CONCLUSIONS: Results from this analysis indicate that there is room for improvement in the availability of FP services by FBOs in these countries. Quality of counseling should be improved by all managing authorities in the three countries, as indicated by low overall coverage for practices such as ensuring confidentiality (22% in Malawi, 47% in Kenya and 12% in Haiti), discussion of sexually transmitted infections (18%, 25%, 17%, respectively), and providing services to youth (53%, 27%, 32%, respectively).

Rapid Assessment of Ebola-Related Implications for Reproductive, Maternal, Newborn and Child Health Service Delivery and Utilization in Guinea.

INTRODUCTION:   Since March 2014, Guinea has been in the midst of the largest, longest, and deadliest outbreak of Ebola Virus Disease ever recorded. Due to sub-optimal health conditions prior to the outbreak, Guinean women and children may have been especially vulnerable to worsening health care conditions. A rapid assessment was conducted to better understand how the delivery and utilization of routine RMNCH services may have been affected by the extraordinary strain placed on the health system and its client population by the Ebola outbreak in Guinea. METHODS:   Data were collected January-February 2015 in a convenience sample of public and private facilities in areas of the country that were Ebola active, calm and inactive. Monthly data on a number of RMNCH services were collected by facility record abstraction for the period from October 1, 2013 through December 31, 2014. Structured interviews were also held with facility directors and RMNCH service providers. RESULTS:   Data on RMNCH services from forty five public facilities were obtained. A statistically significant decline of 31% was seen in outpatient visits between October-December 2013 (before the Ebola outbreak) and October-December 2014 (the advanced stage of the Ebola outbreak). Service declines appeared to be greater in hospitals compared to health centers. Child health services were more affected by the Ebola epidemic than other assessed health areas. For example, the number of children under five seen for diarrhea and Acute Respiratory Infection (ARI) showed a large decrease over the one-year period in both hospitals (60% for diarrhea and 58% for ARI) and health centers (25% and 23%, respectively). RESULTS also suggest that the negative effects on service availability (such as reduced hours, closures, and service suspensions) are likely to be regional and/or facility-specific. Providers reported a number of improved infection control behaviors as a result of the Ebola outbreak, including more frequent hand-washing and the use of disinfectants. Nevertheless, 30% of interviewed staff had not received any training on Ebola infection control.   DISCUSSION:   Although there may be differences in RMNCH service delivery and availability in selected versus non-selected facilities, a large number of indicators were assessed in order to provide needed information on the effects of the Ebola crisis on routine RMNCH service delivery and uptake in Guinea. This information is an important and timely contribution to ongoing efforts to understand and respond to the adverse effects of the Ebola crisis on essential RMNCH services in Guinea.

The effect of access to contraceptive services on injectable use and demand for family planning in Malawi.

CONTEXT: Previous studies have identified positive relationships between geographic proximity to family planning services and contraceptive use, but have not accounted for the effect of contraceptive supply reliability or the diminishing influence of facility access with increasing distance. METHODS: Kernel density estimation was used to geographically link Malawi women's use of injectable contraceptives and demand for birth spacing or limiting, as drawn from the 2010 Demographic and Health Survey, with contraceptive logistics data from family planning service delivery points. Linear probability models were run to identify associations between access to injectable services-measured by distance alone and by distance combined with supply reliability-and injectable use and family planning demand among rural and urban populations. RESULTS: Access to services was an important predictor of injectable use. The probability of injectable use among rural women with the most access by both measures was 7‒8 percentage points higher than among rural dwellers with the least access. The probability of wanting to space or limit births among urban women who had access to the most reliable supplies was 18 percentage points higher than among their counterparts with the least access. CONCLUSIONS: Product availability in the local service environment plays a critical role in women's demand for and use of contraceptive methods. Use of kernel density estimation in creating facility service environments provides a refined approach to linking women with services and accounts for both distance to facilities and supply reliability. Urban and rural differences should be considered when seeking to improve contraceptive access.

Understanding patterns of temporary method use among urban women from Uttar Pradesh, India.

BACKGROUND: Almost one in five contraceptive users in India uses a temporary method. It is important to understand user profiles and method use patterns for optimal program targeting.This analysis examines differences in demographic characteristics, discontinuation and use patterns of temporary method users among a representative sample of urban women from four cities in Uttar Pradesh, India. METHODS: Individual data from a panel of women aged 15-49 were collected in 2010 in Agra, Aligarh, Allahabad, and Gorakhpur and follow-up data from the same women were collected in 2012. A contraceptive calendar was used to collect month-by-month data on contraceptive use, non-use, discontinuation, reason for discontinuation, and pregnancy and birth, covering the approximately two-year period between the baseline and midterm surveys. The analysis sample is 4,023 non-sterilized women in union at baseline. A descriptive comparison is made of socio-demographic characteristics, fertility desires, discontinuation, method switching, and pregnancy outcomes. Reasons for discontinuation are assessed by the order of discontinuation. RESULTS: There were a number of socio-demographic differences between users of temporary methods during the calendar period; by education, wealth, and caste. Notably, women who used only condoms during this time had the most education, were the least likely to be poor, and the least likely to be from a scheduled caste or tribe as compared to users of other temporary methods. Compared to the full sample of women, users of temporary methods during this period were less likely to reside in slum areas. The group of multiple method users was small in comparison to the groups of women using a single method throughout the calendar period. This indicates that there was little method switching between condoms, traditional methods, and other forms of modern methods reported in the calendar. CONCLUSIONS: The calendar may not be well-suited to measure coital-dependent contraceptive use (e.g., condoms and traditional methods), as "continuous" monthly use may be overstated. A coital episode-specific data collection tool may produce more accurate records of contraceptive use in such contexts. Research findings also lead to useful programmatic recommendations for addressing unmet need and unintended pregnancies in urban Uttar Pradesh and beyond.

Indonesian couples' pregnancy ambivalence and contraceptive use.

CONTEXT: Most studies on pregnancy ambivalence are based on data from women and depend on the women's perceptions to measure their partner's pregnancy intentions. Because these perceptions may not be accurate, data collected directly from men are needed to understand the role of couple dynamics in fertility behavior. METHOD: Matched couple data from the 2002-2003 Indonesia Demographic and Health Survey were used to examine contraceptive use, fertility desires and attitudes about becoming pregnant in the next few weeks-whether it would be a big problem, a small problem or no problem. Concordance between partners on these issues was evaluated. Inconsistent fertility desires and responses to the problem question are used to define ambivalence within couples. Multivariate logistic regression analyses were used to assess whether couples' pregnancy ambivalence was associated with contraceptive use. RESULTS: Seventy-one percent of husbands and 54% of wives reported that a pregnancy in the next few weeks would be "no problem"; couples' concordance on this question was 64% among contraceptive users and 61% among nonusers. In the multivariate analysis, couples who were discordant on the issue of a pregnancy in the near future had 26% lower odds of using contraceptives than couples in which both partners agreed a pregnancy would be a big or small problem. Contraceptive use was also less likely for couples in which one partner wanted to delay or stop childbearing and the other wanted more children or was undecided (odds ratio, 0.4). CONCLUSIONS: Husbands and wives influence each other's fertility attitudes and family planning use. Both husbands' and wives' pregnancy attitudes should be taken into account at the time of screening and method selection.

The 2005 census and mapping of slums in Bangladesh: design, select results and application.

BACKGROUND: The concentration of poverty and adverse environmental circumstances within slums, particularly those in the cities of developing countries, are an increasingly important concern for both public health policy initiatives and related programs in other sectors. However, there is a dearth of information on the population-level implications of slum life for human health. This manuscript describes the 2005 Census and Mapping of Slums (CMS), which used geographic information systems (GIS) tools and digital satellite imagery combined with more traditional fieldwork methodologies, to obtain detailed, up-to-date and new information about slum life in all slums of six major cities in Bangladesh (including Dhaka). RESULTS: The CMS found that Bangladeshi slums are very diverse: there are wide intra- and inter-city variations in population size, density, the percent of urban populations living in slums, and sanitation conditions. Findings also show that common beliefs about slums may be outdated; of note, tenure insecurity was found to be an issue in only a small minority of slums. CONCLUSION: The methodology used in the 2005 Bangladesh CMS provides a useful approach to mapping slums that could be applied to urban areas in other low income societies. This methodology may become an increasingly important analytic tool to inform policy, as cities in developing countries are forecasted to continue increasing their share of total global population in the coming years, with slum populations more than doubling in size during the same period.

Imbalances in the health labour force: an assessment using data from three national health facility surveys.

Accurate knowledge of the characteristics of the health labour force that can affect health care production is of critical importance to health planners and policymakers. This study uses health facility survey data to examine characteristics of the primary health care labour force in Nicaragua, Tanzania and Bangladesh. The characteristics examined are those that are likely to affect service provision, including urban/rural distribution, demographic characteristics, and experience and in-service training, for three types of providers (physicians, nurses and auxiliary nurses). The profiles suggest a pattern of urban/rural imbalances in Nicaragua and Tanzania. The Bangladesh facility survey did not include hospitals, thereby making concrete conclusions on the supply and distribution of providers difficult to make. Multivariate logistic regressions are used to assess the relationship between the urban/rural placement of providers by health need, population demand and facility characteristics. Health need, as measured by child mortality rates, does not have a significant association with the placement of providers in either country, unlike population size and annual growth rates. The mean number of years providers have worked at a facility is significantly associated with a decreased likelihood of rural placement for the three types of providers in Nicaragua. The mean age and percentage of female providers at each facility has a negative association with the placement of rural providers in Tanzania. The use of health facility data to profile the health care labour force is also discussed.

Social and proximate determinants of sexual activity in rural Nigeria.

This study analyses the social, physiological and motivational determinants of sexual activity for 644 married women in rural areas of Osun State, Nigeria. The data come from the Fertility Awareness and Pregnancy Avoidance study conducted in 1993-94. Sexual activity is measured by three continuous variables: weekly frequency of (1) total sexual activity, (2) coital-only sex and (3) both coital/non-coital sex. Analyses of variance were performed to test the difference in group means between the predictor variables and measures of sexual activity. Ordinary least squares regression analyses were then performed for the three dependent variables. Two models are used: the first contains only those variables associated with an individual's demographic, social and economic status, and the second adds predictor variables associated with motivational and physiological factors. Results show that while many socioeconomic variables by themselves are significantly associated with sexual activity measures, the addition of physiological and motivational variables weakens their effects and lessens their original statistical significance. Additionally, the socioeconomic and demographic factors associated with frequency of sexual activity are not necessarily the same ones significantly associated with coital-only or combined coital/non-coital sex. While other studies have tended to focus either on socioeconomic or physiological factors, the joint examination of both types of influences seems to indicate that the latter have more proximate effects on the frequency of both coital and non-coital sexual activity of married women in this population. Contraceptive protection is shown to be highly positively associated with all three of the sexual activity measures, empirically confirming the important relationship between contraception and both coital and non-coital forms of sexual activity.