Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys.

BACKGROUND: Data for trends in contraceptive use and need are necessary to guide programme and policy decisions and to monitor progress towards Millennium Development Goal 5, which calls for universal access to contraceptive services. We therefore aimed to estimate trends in contraceptive use and unmet need in developing countries in 2003, 2008, and 2012 . METHODS: We obtained data from national surveys for married and unmarried women aged 15-49 years in regions and subregions of developing countries. We estimated trends in the numbers and proportions of women wanting to avoid pregnancy, according to whether they were using modern contraceptives, or had unmet need for modern methods (ie, using no methods or a traditional method). We used comparable data sources and methods for three reference years (2003, 2008, and 2012). National survey data were available for 81-98% of married women using and with unmet need for modern methods. FINDINGS: The number of women wanting to avoid pregnancy and therefore needing effective contraception increased substantially, from 716 million (54%) of 1321 million in 2003, to 827 million (57%) of 1448 million in 2008, to 867 million (57%) of 1520 million in 2012. Most of this increase (108 million) was attributable to population growth. Use of modern contraceptive methods also increased, and the overall proportion of women with unmet need for modern methods among those wanting to avoid pregnancy decreased from 29% (210 million) in 2003, to 26% (222 million) in 2012. However, unmet need for modern contraceptives was still very high in 2012, especially in sub-Saharan Africa (53 million [60%] of 89 million), south Asia (83 million [34%] of 246 million), and western Asia (14 million [50%] of 27 million). Moreover, a shift in the past decade away from sterilisation, the most effective method, towards injectable drugs and barrier methods, might have led to increases in unintended pregnancies in women using modern methods. INTERPRETATION: Achievement of the desired number and healthy timing of births has important benefits for women, families, and societies. To meet the unmet need for modern contraception, countries need to increase resources, improve access to contraceptive services and supplies, and provide high-quality services and large-scale public education interventions to reduce social barriers. Our findings confirm a substantial and unfinished agenda towards meeting of couples' reproductive needs. FUNDING: UK Department for International Development, the Bill & Melinda Gates Foundation, and the UN Population Fund (UNFPA).

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.

Factors associated with contraceptive choice and inconsistent method use, United States, 2004.

CONTEXT: Pregnancies among contraceptive users account for nearly half of all unintended pregnancies and are almost entirely due to inconsistent or incorrect contraceptive use. Understanding what factors contribute to inconsistent contraceptive behavior can help efforts to reduce unintended pregnancy. METHODS: In 2004, a nationally representative sample of women aged 18-44 using reversible contraceptive methods were surveyed to examine factors associated with contraceptive choice and with inconsistent use of the pill and condoms. Bivariate and multivariate analyses were used to examine the data. RESULTS: Contraceptive choice was associated with a range of socioeconomic and partnership characteristics, and with pregnancy-, method- and provider-related experiences and attitudes; inconsistent pill or condom use was associated mainly with partnership, experiential and attitudinal factors. For example, not having a college education was negatively associated with pill use (odds ratio, 0.6) and positively associated with use of long-acting methods (1.8-1.9). Women for whom avoiding pregnancy was only a little or not important had reduced odds of using the pill (0.4) and elevated odds of using other methods, such as withdrawal or periodic abstinence (4.4), and of using condoms inconsistently (2.6). Use of a method chosen mostly out of dislike of other methods was positively associated with condom use (4.0) and negatively associated with use of the pill or long-acting methods (0.4 for each). Women who were not completely satisfied with their method were more likely than others to use their method inconsistently (1.6 for pill users and 1.9 for condom users). CONCLUSIONS: Greater efforts are needed to provide women and their partners with a range of method options, to facilitate selection of methods that best suit their needs and circumstances, and to identify and assist users who are dissatisfied or are having difficulties using contraceptives effectively.

Male fertility control--where are the men?

Control over the timing and number of children continues to be a challenge for many men and women today. While some men are contraceptive users today, current method options are limited. Evidence indicates that many men would welcome more method options, to meet their own needs and goals and to provide a way for them to participate in contraception in a more collaborative way with their partner.

Harmonizing Methods for Estimating the Impact of Contraceptive Use on Unintended Pregnancy, Abortion, and Maternal Health.

Estimates of the potential impacts of contraceptive use on averting unintended pregnancies, total and unsafe abortions, maternal deaths, and newborn, infant, and child deaths provide evidence of the value of investments in family planning programs and thus are critically important for policy makers, donors, and advocates alike. Several research teams have independently developed mathematical models that estimate the number of adverse health outcomes averted due to contraceptive use. However, each modeling approach was designed for different purposes, and as such the methodological assumptions, data inputs, and mathematical algorithms initially used in each model differed; consequently, the models did not produce comparable estimates for the same outcome indicators. To address this, a series of expert group meetings took place in which 5 models-Adding it Up, Impact 2, ImpactNow, Reality Check, and FamPlan/Lives Saved Tool (LiST)-were reviewed and harmonized where possible. The group identified the main reasons for the inconsistencies in the estimates generated by the models for each of the adverse health outcome indicators. The group then worked together to align the methodologies for estimating numbers of unintended pregnancies, abortions, and maternal deaths averted due to contraceptive use, and reviewed the challenges with estimating the impact of contraceptive use on newborn, infant, and child deaths, including the lack of a conceptually clear pathway and rigorous evidence. The assumption that most influenced harmonization was the comparison pregnancy rate used by the models to estimate the counterfactual scenario-that is, if women who are currently using contraception were not using a method, how many would become pregnant? All the models now base this on the number of unintended pregnancies among women with unmet contraceptive need, bringing the estimates for unintended pregnancies, total and unsafe abortion, and maternal deaths much closer together. The agreed approaches have already been adopted by the Family Planning 2020 (FP2020) initiative and Track20, a project that supports FP2020. The experts will continue to update their models collaboratively to ensure that the most current estimation methodologies and data available are used. Valid and reliable methodologies for estimating these impacts from family planning are critically important, not only for advocacy to sustain resource allocation commitments but also to enable measurement and tracking of global development indicators. Conflicting estimates can be counterproductive to generating support for family planning programs, and this harmonization process has created a more unified voice for quantifying the benefits of family planning.

U.S. insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002.

CONTEXT: In 1993, coverage of reversible contraception by U.S. health insurance plans was extremely low. Little is known about how coverage has changed since then, particularly in response to state mandates. METHODS: In 2001-2002, a nationally representative sample of 205 health care insurers responded to a survey about coverage of reproductive health care services in "typical" employment-based managed care plans (excluding self-insured plans). Data were analyzed to compare coverage in states with and without contraceptive coverage mandates, and to show trends in coverage between 1993 and 2002. RESULTS: In 2002, almost every reversible contraceptive service and supply studied was covered by at least 89% of typical plans; 86% of plans covered the five leading prescription methods (the diaphragm, one- and three-month injectables, the IUD and oral contraceptives). Coverage of each contraceptive service and supply studied was higher in 2002 than in 1993 (78-97% vs. 32-59%). Plans in states with mandates were significantly more likely to cover the five leading prescription methods (87-92%, depending on type of plan) than were those designed locally in states without mandates (47-61%). Between 1993 and 2002, state mandates were estimated to account for 30% and 40% of the increase in coverage of oral contraceptives and the three-month injectable, respectively. CONCLUSIONS: Coverage of reversible contraception--and by extension, choice within a range of covered methods--has increased substantially since 1993, in part because of state mandates. This state-by-state approach, however, has inherent limitations that can best be dealt with at the federal level.

Patterns in the socioeconomic characteristics of women obtaining abortions in 2000-2001.

CONTEXT: Information about the socioeconomic characteristics of women obtaining abortions in the United States can help policymakers and family planning providers determine which groups of women need better access to contraceptive services. METHODS: A representative sample of more than 10,000 women obtaining abortions from a stratified probability sample of 100 U.S. providers were surveyed in 2000-2001; survey data are used to examine the demographic characteristics of women who terminate pregnancies. This information, along with other national-level data, is used to estimate abortion rates and ratios for subgroups of women and examine recent changes in these measures. RESULTS. In 2000, 21 out of every 1,000 women of reproductive age had an abortion. Women who are aged 18-29, unmarried, black or Hispanic, or economically disadvantaged-including those on Medicaid-have higher abortion rates. The overall abortion rate decreased by 11% between 1994 and 2000. The decline was greatest for 15-17-year-olds, women in the highest income category, those with college degrees and those with no religious affiliation. Abortion rates for women with incomes below 200% of poverty and for women with Medicaid coverage increased between 1994 and 2000. The rate of decline in abortion among black and Hispanic adolescents was lower than that among white adolescents, and the abortion rate among poor teenagers increased substantially. CONCLUSIONS: Increased efforts are needed to help both adolescent women and adult women of all economic statuses avoid unintended pregnancies.

Contraceptive use among U.S. women having abortions in 2000-2001.

CONTEXT: Knowing the extent to which contraceptive nonuse, incorrect or inconsistent use, and method failure account for unintended pregnancies ending in abortion, as well as reasons for nonuse and imperfect use, can help policymakers and family planning providers support effective contraceptive use. METHODS: Contraceptive use patterns among a nationally representative sample of 10,683 women receiving abortion services in 2000-2001 were examined, as well as reasons for nonuse, problems with the most frequently used methods and the impact emergency contraceptive pills have had on abortion rates. RESULTS: Forty-six percent of women had not used a contraceptive method in the month they conceived, mainly because of perceived low risk of pregnancy and concerns about contraception (cited by 33% and 32% of nonusers respectively). The male condom was the most commonly reported method among all women (28%), followed by the pill (14%). Inconsistent method use was the main cause of pregnancy for 49% of condom users and 76% of pill users; 42% of condom users cited condom breakage or slippage as a reason for pregnancy. Substantial proportions of pill and condom users indicated perfect method use (13-14%). As many as 51,000 abortions were averted by use of emergency contraceptive pills in 2000. CONCLUSIONS: Women and men need accurate information about fertility cycles and about the risk of pregnancy when a contraceptive is not used or is used imperfectly. Increased use of emergency contraceptive pills could further reduce levels of unintended pregnancy and abortion.

Services for men at publicly funded family planning agencies, 1998-1999.

CONTEXT: Men's reproductive health needs are receiving increased attention, but most family planning clinic clients are female, and clinics have reported barriers to serving men. METHODS: A 1999 survey of publicly funded agencies that administer family planning clinics asked several questions about current policies and services and the number of men served in 1998. Data on 17 services were collected, as well as the proportion of clients who were male and agencies' barriers to serving men. RESULTS: The services most commonly offered to men in 1999 were condom provision and sexually transmitted disease (STD) counseling (95% of all agencies), contraceptive counseling (93%), and STD treatment (90%) and testing (89%). The proportions offering various male reproductive health services were lowest among hospital-based clinics. Eighty-seven percent of agencies served some male contraceptive or STD clients in 1998; those that did served a mean of 255 men and a median of 50. The male client caseload increased between 1995 and 1998 at 53% of agencies, and four out of five agencies were interested in serving more men in the future. The most commonly reported barriers to serving men were men's unawareness that services were available (58%) and inadequate agency funding (55%). CONCLUSIONS: Although most clients of publicly funded family planning agencies are women, a nonnegligible number are men. Additional efforts are needed to determine the best way to deliver reproductive health services to men.

Factors associated with the content of sex education in U.S. public secondary schools.

CONTEXT: While sex education is almost universal in U.S. schools, its content varies considerably. Topics such as abstinence, and basic information on HIV and other sexually transmitted diseases (STDs), are commonly taught; birth control and how to access STD and contraceptive services are taught less often. Factors potentially associated with these variations need to be examined. METHODS: Data on 1,657 respondents to a 1999 national survey of teachers providing sex education in grades 7-12 were assessed for variation in topics covered. Logistic regression was used to ascertain factors associated with instruction on selected topics. RESULTS: The content of sex education varied by region and by instructors' approach to teaching about abstinence and contraception. For example, teaching abstinence as the only means of pregnancy and STD prevention was more common in the South than in the Northeast (30% vs. 17%). Emphasizing the ineffectiveness of contraceptives was less common in the Northeast (17%) than in other regions (27-32%). Instructors teaching that methods are ineffective and presenting abstinence as teenagers' only option had significantly reduced odds of teaching various skills and topics (odds ratios, 0.1-0.5). CONCLUSIONS: Instructors' approach to teaching about methods is a very powerful indicator of the content of sex education. Given the well-documented relationship between what teenagers learn about safer sexual behavior and their use of methods when they initiate sexual activity, sex education in all U.S. high schools should include accurate information about condoms and other contraceptives.

U.S. agencies providing publicly funded contraceptive services in 1999.

CONTEXT: Nearly one-quarter of women who obtain medical contraceptive services receive care from clinics operated by publicly funded agencies. In light of changes in government policy and funding and in the structure of health care financing, an assessment of agency policies and programs is essential for monitoring women's access to contraceptive care and services. METHODS: In 1999, 637 of a nationally representative sample of 1,016 U.S. agencies that receive public funding to provide contraceptive services responded to a 12-page survey. Responses were analyzed according to agency type, receipt of Title X funding and main focus. RESULTS: More than nine in 10 agencies offer the pill, the male condom and the injectable; 80% offer emergency contraceptive pills, compared with 38% in 1995. Some agencies allow clients to delay a pelvic exam when beginning use of oral contraceptives (56%), the injectable (42%) or the implant (23%). On average, agencies receive funding for contraceptive services from 4.9 sources; the proportion relying on private insurance and contributions has risen since 1995. Virtually all family planning agencies provide screening and testing for sexually transmitted diseases (STDs), and at least two-thirds offer treatment for most STDs. The vast majority of agencies offer general health care and perinatal or pediatric services; half offer general gynecologic care or infertility services. Services provided, costs and clinic policies vary according to agency type. CONCLUSIONS: Agencies offering contraceptive services also offer a wide range of reproductive health and related services. There remain services for which provision could be increased and policies that need to be modified to facilitate clients' access to contraceptive care.

Issues in measuring HIV prevalence: the case of Nigeria.

This article reviews methodologies and data sources that have been used to measure HIV prevalence and sexual behaviours associated with the transmission of HIV in Nigeria. The review includes 35 studies on HIV prevalence and methodology and 34 studies on sexual behaviour published between 1990 and 2000. As at 1999, 5.1-5.4% of the general population was estimated to be infected with HIV. Trend data, although limited, indicate that HIV prevalence is increasing among both the general population and specific subgroups. Data on sexual behaviours indicate that risk behaviours are very common in Nigeria while condom use remains low. Studies in local areas and on population subgroups indicate great variability in both HIV prevalence and sexual risk behaviour. Comparability of data is limited as a result of differences in design and measurement across studies. Also, there is a dearth of information on certain groups at high risk for HIV. Despite efforts to establish and improve HIV surveillance in Nigeria, this review illustrates limitations and challenges undoubtedly shared by other countries.

Trends in contraceptive use.

BACKGROUND: In the past 50-60 years, desired and actual family size have decreased and contraceptive use has increased, especially in developing countries. Unmet need for modern contraceptives and unintended pregnancy levels remain significant. STUDY DESIGN: Data compiled by the United Nations and information from national surveys of women of reproductive age are used to examine trends. RESULTS: Oral contraceptives and condoms have been predominant methods in developed countries; sterilization has been the most common in Latin America and the Caribbean and Asia; hormonal methods, in Africa. Some 222 million women in developing countries have unmet need for modern contraceptives, resulting in 2012 in an estimated 54 million unintended pregnancies and 79,000 maternal deaths more than if they used modern methods. CONCLUSIONS: Improvements are needed in contraceptive information and services as well as in contraceptive methods themselves to increase couples' success in achieving their desired timing and number of children.

Meeting women's contraceptive needs in the Philippines.

The ability to practice contraception is essential to protecting Filipino women's health and rights. Yet low levels of use have led to high levels of unintended pregnancy in the Philippines, for which women and society pay dearly-- in lives, family well-being and public funds.

Contraception: an investment in lives, health and development.

Women's ability to practice contraception is essential to protecting their health and rights. Reproductive health care--including contraceptive services--enables women and their partners to make choices about pregnancy, have healthy babies and protect themselves from infections. Contraception also promotes economic development. An investment in contraceptive services can be recouped four times over--and sometimes dramatically more--by reducing the need for public spending on health, education and other social services.

Improving contraceptive use in the United States.

The average American woman--who wants two children--spends about three decades trying to avoid pregnancy and only a few years trying to become or being pregnant. Sexually active women who are not seeking pregnancy may nonetheless practice contraception poorly or may not use a method at all. A wide range of reasons explain this seeming contradiction, including personal feelings and beliefs; experiences with methods; fears about side effects; partner influences; cultural values and norms; and problems in the contraceptive care system. Helping women prevent unintended pregnancy requires a broad-based approach that addresses many of these issues. To identify possible strategies for improving contraceptive use in the United States, two nationally representative surveys investigated women's contraceptive experiences and clinicians' delivery of relevant care. One survey asked sexually active women aged 18-44 who were not seeking pregnancy about their contraceptive use patterns over a one-year period. We focused on adults because many studies have examined adolescents' behavior, and relatively little is known about the contraceptive difficulties experienced by adult women--who account for more than 90% of unintended pregnancies. The second survey asked public and private contraceptive service providers to describe their service delivery protocols and their perceptions of clients' difficulties with method use. Results of these surveys reveal a complex picture of women's motivation and of client-provider interactions that sometimes hinder effective contraceptive use. They also suggest a number of measures that providers can take to help clients improve their contraceptive practice--many of which would require only simple changes in counseling practices and clinical protocols--and that policymakers, researchers and advocates can take to help in this effort.

Religious differentials in the sexual and reproductive behaviors of young women in the United States.

PURPOSE: To examine whether religious involvement and affiliation during early adolescence is associated with reduced levels of sexual risk. METHODS: We used nationally representative data from the 1995 National Survey of Family Growth (NSFG) to examine the relationship between religious affiliation and frequency of attendance at religious services at age 14 years and a range of sexual behaviors among women aged 15-24 years, including age of first intercourse, contraceptive use, timing of first family planning visit, timing of birth, and number of sexual partners. The majority of young women had mothers with at least a high school education (79%) and had been living with both parents at age 14 (57%). Two-thirds of the sample was white, 12% Hispanic, and 15% black, and a substantial minority is poor (18%) or low-income (24%). We used bivariate analysis to describe variation in behavior according to religious affiliation and frequency of attendance. We used multivariate techniques to assess the role of religion once other factors are taken into account. RESULTS: Bivariate relationships suggest that both affiliation and attendance are associated with age of first sex, contraceptive use at first sex, teen births, and number of sexual partners. However, most of these associations disappear once we control for young women's demographic characteristics. Multivariate analyses show that religious affiliation shares few associations with sexual behaviors, though frequent attendance at religious services at age 14 years continues to have a strong delaying effect on the timing of first intercourse. CONCLUSION: Frequency of attendance and religious affiliation have little impact on sexual behaviors once intercourse occurs.

A, B and C in Uganda: the roles of abstinence, monogamy and condom use in HIV decline.

Uganda is often cited as a role model in the fight against HIV/AIDS because of its success in reducing both prevalence and incidence of HIV infection since the late 1980s. Although an increase in sexual abstinence has been highlighted as a primary cause of the declines, large increases have also been recorded in monogamy and condom use. The extent to which each of these factors actually influenced the overall decline in Uganda's HIV rates has become a highly charged political issue in the United States, leading to restrictions on how US development funding for combatting HIV is allocated. The Alan Guttmacher Institute investigated changes that occurred in abstinence, monogamy and condom use in Uganda in the 1990s, using nationally representative data from Uganda's Demographic and Health Surveys of 1988 (women only), 1995 and 2000 (women and men), and national-level findings from two surveys by the Global Programme on AIDS in 1989 and 1995 (women and men). Reduction of infection risk by lowering numbers or types of partners among people with more than one relationship was not covered. Here we reprint the chapter on "Implications" from the AGI report, a commentary on the lessons that can and cannot be taken from the data, published in a 2003 Guttmacher Report on Public Policy.