Maternal healthcare use by women with disabilities in Rajasthan, India: a secondary analysis of the Annual Health Survey.

BACKGROUND: Women with disabilities face a number of barriers when accessing reproductive health services, including maternal healthcare. These include physical inaccessibility, high costs, transportation that is not accessible, negative attitudes from family and healthcare providers, and a societal belief people with disabilities shouldn't be parents. While qualitative studies have uncovered these barriers, there is limited quantitative research to determine their effect on use of maternal health services. This study aims to analyze associations between disability and maternal healthcare use among married women in Rajasthan. METHODS: This study is a secondary analysis of the Indian Annual Heath Survey first wave data from 2011. The sample includes 141,983 women aged 15-49 who had given birth between 2007 and 2009. Logistic regression was used to assess the association between disability and use of antenatal, delivery, and postnatal care. Stratified models were created to analyze difference based on birth order of the pregnancy and whether the woman's place of residence is rural or urban. RESULTS: The prevalence of disability was 1.23%. Attending at least three antenatal care visits was reported by 50.66% of the sample, skilled delivery use by 83.81%, and receiving postnatal care within 48 h of birth by 76.02%. In the regression model, women with disabilities were less likely to report attending the minimum antenatal care visits (OR = 0.84; CI: 0.76, 0.92). No association was found between disability and skilled delivery or postnatal care. Once the sample was stratified by birth order, women with disabilities reporting their first birth were more likely to report receiving postnatal care than women without disabilities (OR = 1.47; CI: 1.13, 1.91). CONCLUSION: Additional research is needed to determine use of maternal healthcare among women with disabilities in India. Maternal services need to be assessed to determine their accessibility, especially regarding recent laws requiring accessibility.

Longitudinal Examination of Which Married Young Women Use Contraception to Delay a First Pregnancy in Bihar and Uttar Pradesh, India.

Early marriage and childbearing put young women and their babies at risk of poor health and well-being. This study uses two rounds of longitudinal data from young women ages 15-19 in 2015-2016 and followed in 2018-2019 to determine factors associated with contraceptive use before a first pregnancy among young, married women in Bihar and Uttar Pradesh, India. Discrete time hazard models were used to analyze time to first use starting from the month of marriage. Overall, use of contraception prior to a first pregnancy was low in this sample (between 12 to 20% used before a first pregnancy). Young women who reported that someone discussed the importance of delaying a first birth at the time of marriage were significantly more likely to have used a method of family planning (FP) before a first pregnancy than those who did not receive this information. Further, women who discussed FP with their husband before a first pregnancy were more likely to use contraception. Finally, among recently married young women, those who experienced pressure to have a child were less likely to use before a first pregnancy. As young women recognize the advantages of delaying a first birth and adopt FP to meet their needs, social norms around early childbearing will slowly adjust and early use to delay a first pregnancy will become more normative.

The more, the better: influence of family planning discussions during the maternal, newborn and child health continuum of care on postpartum contraceptive uptake and method type among young women in Ethiopia.

Background: This study examines the association between family planning (FP) discussions with health professionals during contact points on the maternal, newborn and child health continuum of care and timing of modern contraceptive uptake and method type in the one-year following childbirth in six regions of Ethiopia among adolescent girls and young women (AGYW). Methods: This paper uses panel data of women aged 15-24 who were interviewed during pregnancy and the postpartum period between 2019-2021 as part of the PMA Ethiopia survey (n=652).  Results: Despite the majority of pregnant and postpartum AGYW attending antenatal care (ANC), giving birth in a health facility, and attending vaccination visits, one-third or less of those who received the service reported discussion of FP at any of these visits. When considering the cumulative effect of discussions of FP at ANC, pre-discharge after childbirth, postnatal care and vaccination visits, we found that discussion of FP at a greater number of visits resulted in increased uptake of modern contraception by one-year postpartum. A greater number of FP discussions was associated with higher long-acting reversible contraceptive use relative to non-use and relative to short-acting method use. Conclusions: Despite high attendance, there are missed opportunities to discuss FP when AGYW access care.

"So let me give you money, you give me what I want": decision-making priorities around contraceptive method and source choice among young women in Kenya.

BACKGROUND: Many factors influence young women's choice of contraceptive methods and where to source them, yet less is known about whether one of these choices (method or source) is prioritized and the relationship between these choices. This study qualitatively explored decision-making around contraceptive method and source choice among young women in Kenya. METHODS: In August-September 2019, 30 in-depth interviews were conducted with women ages 18-24 who had used two or more contraceptive methods and resided in three counties: Nairobi, Mombasa or Migori. Participants were recruited from public and private health facilities and pharmacies. Interview guides captured information about decision-making processes for each contraceptive method the respondent had ever used. Responses were audio-recorded, transcribed, translated into English, coded, and analyzed thematically. RESULTS: The majority of respondents knew which method they wanted to use prior to seeking it from a source. This was true for all types of methods that women ever used. Of the small number of respondents who selected their source first, most were in the post-partum period or experiencing side effects and sought counseling at a source before choosing a method. CONCLUSIONS: This study highlights the importance of providing young women with high quality counseling that provides full information about contraceptive options and addresses that young women's needs vary along the reproductive health continuum of care. This will ensure that young women have information to inform future contraceptive decision-making prior to seeking care.

Qualitative assessment of providers' experiences with a segmentation counseling tool for family planning in Niger.

INTRODUCTION: This study examines experiences with a family planning segmentation counseling tool that is used during the provision of family planning services. Based on answers to a series of questions, women are segmented into one of five categories of family planning users and counseled based on their identified segment. This study aimed to qualitatively assess provider perspectives on implementation of the tool. METHODS: Semi-structured in-depth interviews took place in the Dosso region of Niger among 16 family planning providers who had been trained in segmentation and were currently using the segmentation tool. The facilities chosen for interviews were part of a larger mixed methods study assessing the impact of using the segmentation approach. Interview questions focused on training, supervision, how segmentation occurs at the health facility, how segmentation changes provider-client interactions, and any difficulties faced with implementation. Interviews were translated and transcribed into French and data were coded and thematically analyzed. RESULTS: All providers in the study reported positive outcomes associated with segmentation. While providers acknowledged that the segmentation approach added time to the clinic visit, they did see the benefit of this extra time in providing more meaningful interactions between clients and providers, leaving clients with a deeper understanding of family planning and of the different methods available. The implementation of the tool did not change other aspects of service delivery, except that a segmentation sheet was required to be filled in and kept in each patient's file. Difficulties reported included translating the segmentation tool questions into local languages, training enough health care providers and avoiding stock outs of the segmentation sheets. CONCLUSION: The segmentation process is of benefit to family planning clients in Niger and the scale-up of the strategy could bring higher quality services to women. If this approach is brought to scale the implementation challenges uncovered need to be addressed, especially adequate training. Further research is needed to determine if segmentation leads to changes in family planning use outcomes.

This is a study about what nurses and other health care staff in Niger think about a segmentation counseling tool that is used during family planning services. Segmentation means that during counseling each woman is asked a series of questions and, depending on her answers, she is segmented into one of five 'client type' categories and counseled based on that 'client type' or segment. Face-to-face interviews with health care staff took place in the Dosso region of Niger among 16 staff who were using the tool with their patients. The facilities chosen for interviews were part of a larger study assessing how well segmentation was working. Staff were asked about training, supervision, how segmentation occurs at the facility, how segmentation changes how they interact with patients, and any difficulties faced with implementation. All the interviews were then analyzed. All providers in the study had positive things to say about segmentation, including the benefit of spending extra time with each client. This extra time results in more meaningful interactions between clients and providers, leaving clients with a deeper understanding of family planning and of the different methods available. Difficulties reported included translating the segmentation tool questions into local languages, training enough health care providers and avoiding stock outs of the segmentation sheets. The segmentation process is of benefit to family planning clients in Niger and can contribute to higher quality family planning services for women. The challenges that were found need to be addressed, especially adequate training.

Community perspectives on family planning service quality among users and non-users: a qualitative study from two cities in Burkina Faso.

BACKGROUND: Most studies that focus on quality of family planning (FP) services collect data from facilities. These studies miss the perspectives of quality from women who do not visit a facility and for whom perceived quality may be a barrier to service utilization. METHODS: This qualitative study from two cities in Burkina Faso examines perceived quality of FP services from women who were recruited at the community level to avoid potential biases based on recruiting women at facilities. Twenty focus group discussions were undertaken with varying groups of women of different ages (15-19; 20-24; 25+), marital statuses (unmarried; married), and current modern contraceptive use experiences (current non-users; current users). All focus group discussions were undertaken in the local language and transcribed and translated into French for coding and analysis. RESULTS: Women discuss FP service quality in a variety of locations, depending on their age group. Perspectives on service quality for younger women are often informed by others' experiences whereas for the older women, they are formed by their own and others' experiences. Two important aspects of service delivery emerge from the discussions including interactions with providers and selected system-level aspects of service provision. Important components of provider interactions relate to (a) the initial reception from the provider, (b) the quality of counseling received, (c) stigma and bias from providers, and d) privacy and confidentiality. At the health system level, discussions revolved around (a) wait time; (b) stockouts of methods; (c) costs of services/methods; (d) the expectation for tests as part of service provision; and (e) difficulties with method removal. CONCLUSIONS: To increase contraceptive use among women, it is crucial to address the components of service quality they identify as related to higher quality services. This means supporting providers to offer services in a more friendly and respectful manner. In addition, it is important to ensure that full information is provided to clients on what to expect during a visit to avoid false expectations that lead to poor perceived quality. These types of client-focused activities can improve perceptions of service quality and ideally support use of FP to meet women's needs.

Choice of a family planning outlet in urban areas: The role of distance and quality of services in Kenya and Uganda.

Introduction: Quality of care and physical access to health facilities affect facility choice for family planning (FP). These factors may disproportionately impact young contraceptive users. Understanding which components of service quality drive facility choice among contraceptive users of all ages can inform strategies to strengthen FP programming for all potential users of FP. Methods: This study uses data from Population Services International's Consumer's Market for Family Planning (CM4FP) project, to examine drivers of facility choice among female FP users. The data collected from female contraceptive users, the outlet where they obtained their contraceptive method, and the complete set of alternative outlets in select urban areas of Kenya and Uganda were used. We use a mixed logit model, with inverse probability weights to correct for selection into categories of nonuse and missing facility data. We consider results separately for youth (18-24) and women aged 25-49 in both countries. Results: We find that in both countries and across age groups, users were willing to travel further to public outlets and to outlets offering more methods. Other outlet attributes, including signage, pharmacy, stockouts, and provider training, were important to women in certain age groups or country. Discussion: These results shed light on what components of service quality drive outlet choice among young and older users and can inform strategies to strengthen FP programming for all potential users of FP in urban settings.

"You could find a good or a bad provider, I would say you just have to go and see": A qualitative study of the influence of perceptions of service quality on family planning service use in Burkina Faso.

This qualitative study from Burkina Faso explores community-level perceptions of family planning (FP) service quality among FP users and non-users. It examines how perspectives on service quality may influence women's motivation to seek modern methods from health facilities. For this study, twenty focus group discussions were undertaken with non-users and current users of modern FP including unmarried, sexually active women ages 15-19 and 20-24 and ever married women ages 15-24 and 25+ in Bobo Dioulasso and Banfora, Burkina Faso. The findings demonstrate that respondents prioritized a welcoming environment, positive provider-client exchanges, the full provision of information (especially about side-effects), a pain-free experience, a short waiting time, and privacy and confidentiality. Poor service quality did not, in general, reduce women's demand or need to use a FP method. Some women who were reluctant to use formal health services used a non-facility-based method (calendar method, withdrawal, condoms or abstinence). Importantly, many unmarried, younger women and adolescents, who were more likely to be stigmatized by providers, exhibited agency by proactively seeking a method despite the potential for a negative experience. They prioritized their health and wellbeing over and above any interpersonal barriers they were likely to encounter. Incorporating strategies to improve the quality of FP services based on locally defined elements of quality should be a specific programmatic goal. These strategies can be identified through quality assessments employing a woman-centered lens. Women who visit facilities can be encouraged to share their positive experiences with their networks to improve community-level perspectives of facility quality. Improving service quality can attract new users, especially adolescents, and retain those who have already adopted a FP method. Through these multi-pronged actions, women's (and community) expectations and experience of quality can improve. This, in turn, may lead to greater client satisfaction and associated higher FP prevalence.

The association of quality contraceptive counseling measures with postabortion contraceptive method acceptance and choice: results from client exit interviews across eight countries.

The availability of a variety of modern contraceptive methods is necessary but insufficient to provide a high-quality contraceptive service to postabortion clients. Women, especially young women, must be empowered to make informed choices about which methods they receive, including whether to use contraception following an abortion service. In this study, we conducted 2,488 client exit interviews with abortion clients after their induced abortion service or postabortion care visit in Ipas-supported health facilities in eight countries: Argentina, Bolivia, Ethiopia, Kenya, Mexico, Nepal, Nigeria, and Uganda. We evaluated the quality of postabortion contraceptive counseling across two domains of contraceptive counseling: information exchange and interpersonal communication. We measured the association between these quality elements and two outcomes: 1) client-perceived choice of contraceptive method and 2) whether or not the client received a modern contraceptive method. We examined these relationships while adjusting for sociodemographic and confounding variables, such as the client feeling pressure from the provider to accept a particular method. Finally, we determined whether associations identified differ by age group: under 25 and 25+. Information exchange and interpersonal communication both emerged as important counseling domains for ensuring that clients felt they had the ability to choose a contraceptive method. The domain of information exchange was associated with having received a contraceptive method for all abortion clients, including young abortion clients under 25. Nearly 14% of clients interviewed reported pressure from the provider to accept a particular contraceptive method; and pressure from the provider was significantly associated with a client's perception of not having a choice in selecting and receiving a contraceptive method during her visit to the facility. Improving interpersonal communication, strengthening contraceptive information exchange, and ensuring clients are not pressured by a provider to accept a contraceptive method, must all be prioritized in postabortion contraceptive counseling in health facilities to ensure postabortion contraceptive services are woman-centered and rights-based for abortion clients.

Using structural equation modeling to examine the influence of family planning social norms on modern contraceptive use in Nigeria.

Despite high knowledge of family planning (FP) among Nigerian women, use of modern contraceptives remains low. While FP investments in Nigeria have been ongoing for decades, relatively little emphasis on contextual and structural factors may have contributed to low demand for and use of contraception. From 2009 to 2014, the Bill & Melinda Gates Foundation (BMGF) supported the Nigerian Urban Reproductive Health Initiative (NURHI) with the aim of increasing voluntary use of contraceptives among women ages 15-49 years in six Nigerian cities. A subsequent phase of NURHI was implemented in three states for the next 3 to 5 years. Using cross-sectional survey data from three cities (two exposed to NURHI, one not exposed), this study examines whether social norms around FP were related to women's use of modern contraception, and whether the relationship differed by varying levels of exposure to the program (i.e., by city). We identified three distinct FP social norms through factor analysis: norms around delaying first pregnancy; spacing or limiting pregnancies; and using contraception when the husband disagrees. Using structural equation modeling, we found that FP social norms are related to use of modern contraceptive methods, and the relationship varies by city and norm type. The observed differences suggest that this relationship depends on numerous factors at the individual, interpersonal and societal level, and this may include malleable factors influenced by the NURHI program.

Stigma in the health clinic and implications for PrEP access and use by adolescent girls and young women: conflicting perspectives in South Africa.

BACKGROUND: Globally, an urgent need exists to expand access to HIV prevention among adolescent girls and young women (AGYW), but the need is particularly acute in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) offers an effective HIV prevention method. In many countries, however, accessing PrEP necessitates that AGYW visit their local health clinic, where they may face access challenges. Some countries have implemented youth-friendly services to reduce certain challenges in local health clinics, but barriers to access persist, including clinic stigma. However, evidence of clinic stigma toward AGYW, particularly with respect to PrEP service delivery, is still limited. This mixed methods study explores stigma toward AGYW seeking clinic services, in particular PrEP, from the perspective of both clinic staff (clinical and nonclinical) and AGYW who seek services at clinic sites in Tshwane province, South Africa. METHODS: Six focus group discussions were conducted with AGYW (43 total participants) and four with clinic staff (42 total participants) and triangulated with survey data with AGYW (n = 449) and clinic staff (n = 130). Thematic analysis was applied to the qualitative data and descriptive statistics were conducted with the survey data. RESULTS: Four common themes emerged across the qualitative and quantitative data and with both AGYW and clinic staff, although with varying degrees of resonance between these two groups. These themes included (1) clinic manifestations of stigma toward AGYW, (2) concerns about providing PrEP services for AGYW, (3) healthcare providers' identity as mothers, and (4) privacy and breaches of confidentiality. An additional theme identified mainly in the AGYW data pertained to stigma and access to healthcare. CONCLUSION: Evidence is needed to inform strategies for addressing clinic stigma toward AGYW, with the goal of removing barriers to PrEP services for this group. While awareness has increased and progress has been achieved around the provision of comprehensive, youth-friendly sexual and reproductive health services, these programs need to be adapted for the specific concerns of young people seeking PrEP services. Our findings point to the four key areas noted above where programs seeking to address stigma toward AGYW in clinics can tailor their programming.

Providers' views on hormonal family planning methods for young women: a qualitative study from Dosso, Niger.

Background: Family planning (FP) providers play an important role in ensuring that clients are offered a full range of FP methods. This qualitative study explores providers' views on three hormonal FP methods and why they think women may choose these methods in Niger.                                                    Methods: In-depth interviews were conducted with 24 FP providers in 24 government health centers in Dosso region, Niger between February-March 2020. Providers were asked about the suitability of different FP methods for women, including adolescents and married women with children. The interviews were translated and transcribed from Hausa and Zarma into French, thematically coded, and qualitatively analyzed. Results: Many providers believed discretion to be the most important method attribute for women. Providers report preferring implants for young clients because of the more rapid return to fertility. They disagreed on whether implants or injectables are more discrete for clients. That said, providers felt that clients appreciate the implant's discretion, effectiveness, long-acting nature, and simplicity of use.  Providers perceived that the majority of women choose injectables due to familiarity with the method, the fact that it is "invisible" to an outsider, and a lack of awareness of implants. Providers stated that while women may not initially choose the implant, when given more information about it, they were more open to adopting it, or switching from another method, and less likely to believe local myths. Providers believed that women find pills to be indiscreet. Conclusions: The findings highlight that while providers have perspectives on suitable methods for certain women, they also recognize that clients have their own preferences, such as how discreet the method is. As programs continue to expand method choice and new contraceptive technologies undergo research and development, highly desirable features such as discretion need to be considered.

Contraceptive method use trajectories among young women in Kenya: A qualitative study.

Background: Many young women experience important key life transitions during adolescence and early adulthood, such as initiation of sexual activity, first use of contraceptives, marriage, and childbirth. For young women to be able to plan and manage their lives, it is critical to understand how these life events intersect and shape their contraceptive decision-making. This study aims to explore young women's contraceptive method use trajectories, including the factors that influence contraceptive decision-making throughout adolescence and youth. Methodology: In 2019, the Full Access, Full Choice project (FAFC), implemented by the University of North Carolina at Chapel Hill and the African Institute for Development Policy, conducted 30 in-depth interviews with young women aged 18-24 years in three counties in Kenya (Nairobi, Mombasa and Migori). Eligible respondents had used two or more modern contraceptive methods. Interview guides utilized a modified life history approach to capture details about respondents' contraceptive use and life experiences from the time they first used contraception until the time of interview. Results: We identified five separate contraceptive use trajectories based on the occurrence and timing of marriage, childbirth, and contraceptive method choice as well as various influences on contraceptive decision-making. The majority of respondents began their contraceptive journey by using male condoms or emergency contraception, but subsequent contraceptive decisions were varied across trajectories and influenced by different factors. For many women, the initiation of a non-coitally dependent method occurred after the birth of a child; for some, this was the first method used. Once women transitioned to using a non-coitally dependent method such as injectables or implants, many cycled through different methods to find one that had fewer side effects or provided the desired duration of protection. Discussion: This study highlights the nuanced needs of young women throughout their adolescent and youth years in Kenya. This suggests that programs and policies need to encompass young women's diversity of experiences and motivations to best serve them.

"I Got What I Came for": A Qualitative Exploration into Family Planning Client Satisfaction in Dosso Region, Niger.

Background: Client satisfaction is recognized as an important construct for evaluating health service provision, yet the field of family planning (FP) lacks a standard approach to its measurement. Further, little is known about satisfaction with FP services in Niger, the site of this study. This study aims to understand what features of FP visits were satisfactory or dissatisfactory from a woman's perspective and reflect on the conceptualization and measurement of satisfaction with FP services. Methods: Between February and March 2020, 2720 FP clients (ages 15-49) were interviewed across 45 public health centers in Dosso region, Niger using a structured survey tool. The focus of this paper is on a random sub-sample of 100 clients who were additionally asked four open-ended questions regarding what they liked and disliked about their FP visit. Responses were audio-recorded, translated into French, transcribed, translated into English, coded, and analyzed thematically. Results: FP clients described nine key visit attributes related to their satisfaction with the visit: treatment by the provider, content of the counseling, wait time, FP commodity availability, privacy, cleanliness/infrastructure, visit processes and procedures, cost, and opening hours. The reason for FP visit (start, continue, or change method) was an important driver of the dimensions which contributed to satisfaction. Pre-formed expectations about the visit played a critical role in shaping satisfaction, particularly if the client's pre-visit expectations (or negative expectations) were met or not and if she obtained what she came for. Conclusion: This study makes a significant contribution by identifying visit attributes that are important to FP clients in Dosso region, Niger, and highlights that satisfaction with FP services is shaped by more than just what occurs on the day of service. We propose a conceptual framework to understand satisfaction with FP services that can be used for future FP programming in Niger.

Longitudinal examination of young married women's fertility and family planning intentions and how they relate to subsequent family planning use in Bihar and Uttar Pradesh India.

OBJECTIVES: This study examines which fertility and family planning (FP) intentions are related to subsequent FP use in a sample of young, married women in India. DESIGN: We use 3-year longitudinal data from married women ages 15-19 in 2015-2016 (wave 1) who are not using contraception to examine factors associated with any use of FP in 2018-2019 (wave 2). SETTING: Data were collected in the states of Bihar and Uttar Pradesh, India. PARTICIPANTS: A representative sample of 4893 young married women ages 15-19 was surveyed in 2015-2016 and 4000 of them were found and interviewed 3 years later. This analysis focused on the 3614 young women who were not using FP at wave 1. PRIMARY OUTCOMES: This study examines FP use at wave 2 as the main outcome variable. RESULTS: Multivariate analyses demonstrated that young women who wanted to delay childbearing three or more years or who did not want any(more) children at wave 1 were more likely to use contraception at wave 2. Additionally, intention to use FP in the next 12 months at wave 1 was significantly associated with FP use at wave 2 whereas unmet need at wave 1 was not significantly related to subsequent use. A combined measure of fertility desires and intention to use FP demonstrated the importance of both measures on subsequent use. Having any children and being pregnant at wave 1 were both related to FP use at wave 2. CONCLUSIONS: It is important to reach young, married women prior to a first pregnancy with nuanced messages addressing their fertility and FP intentions. Programmes targeting women at antenatal and postpartum visits are important for young women to help support them to use FP to address their desires to delay or limit future childbearing for the health and well-being of themselves and their children.

Use of modern contraceptives by women with disabilities in Rajasthan, India: An analysis of the annual health survey.

OBJECTIVE: The objective of this study is to analyze associations between disability and contraceptive use among married women in Rajasthan, India. METHODS: The study uses secondary analysis of the Rajasthan dataset of the 2010-2011 Annual Heath Survey. This survey included both disability and reproductive health data. The sample includes 238,240 women aged 15-49 years. Logistic regression is used to measure associations between disability status and use of modern contraceptives and female sterilization in the sample. Stratified analyses by age and residence were also conducted. RESULTS: The prevalence of disability among women of reproductive age was 0.9%. Modern contraceptive use was reported by 73.0% of the sample, and female sterilization by 57.7% of the sample. Women with disabilities (WWD) were less likely to report using a modern contraceptive (OR 0.87, 95% CI: 0.78, 0.95). Among modern method users, WWD were not significantly more likely to be using sterilization than another modern method; however, there were significantly higher odds of sterilization versus another modern method for urban WWD (OR 1.57, 95% CI: 1.11, 2.22). CONCLUSIONS: In this study, disability was associated with contraceptive use. Additional research is needed to determine if there is a causal relationship between disability and contraceptive use. Family planning providers should be trained to provide care to WWD and the Government of India should ensure the National Family Planning Programme is accessible to people with disabilities.

Perceptions of peer contraceptive use and its influence on contraceptive method use and choice among young women and men in Kenya: a quantitative cross-sectional study.

BACKGROUND: Prior research has established that an individual's social environment may influence his or her reproductive behaviors, yet less is known about peer influence on contraceptive use among young people (ages 15-24). In Kenya, the site of this study, 15% of adolescents ages 15-19 have begun childbearing and 45% of sexually active young women report current use of a modern contraceptive method. This highlights the need to better understand what factors influence young people to use contraception. The objective of this study is to explore the relationship between the perception of peers' use of contraceptives and contraceptive use and method choice among young men and women in Kenya. METHODS: This study utilizes a nationally representative sample of women and men aged 15-24 years from the 2018 and 2019 cross sectional Shujaaz State of the Kenyan Youth annual surveys. Among the sample of sexually experienced young people (59%), multivariable multinomial logistic regression was used to explore the association between the perception of peers' use of contraceptives and the respondent's contraceptive method choice: non-user, condom use or use of any other modern method. Results are presented separately for young men and young women. RESULTS: Our results show that sexually experienced young men and women who perceive that their peers are using contraceptives are more likely to report current use of condoms compared to being a nonuser (RRR = 2.12, p < 0.001, RRR = 2.59, p < 0.001, respectively); they are also more likely to use condoms than another modern method of contraception (RRR = 2.13, p = 0.034, RRR = 1.71, p = 0.014, respectively). Young women are more likely to use another modern method (not including condoms) than be a nonuser when they perceive that their peers' use contraceptives (RRR = 1.51, p = 0.020). CONCLUSIONS: The results of this study highlight the important role of peer influence on young people's contraceptive choices. These findings can be used to develop programs that encourage behavior change communication activities in Kenya that focus on normalizing use of a full range of contraceptive methods among peer groups of sexually experienced young people.

In Kenya, about 15% of women age 15­19 have already had a birth and approximately one third of these women did not want to have a child at that time. Yet about 45% of sexually active women ages 15­24 report that they currently use family planning (FP). Among young people, friends and peers are an important influence on behaviors.This study focused on a representative sample from Kenya of female and male youth (ages 15­24) who ever had sex. Men and women were asked questions about use of FP, if they think their peers use FP and about characteristics such as age and education.The results showed that young women and men who believed their peers use FP were more likely to use FP themselves. Also, young men and women who believed that peers use FP were more likely to use condoms than not use any FP and more likely to use condoms than to use another modern method of FP. Young women who thought their peers use were more likely to use another modern method (not including condoms) than to be a nonuser of FP.Programs targeting young people should include information on a range of FP methods and aim to include groups of peers and encourage open discussion.

Does Provider Bias Affect Choice of a Facility for Family Planning Services by Women in Urban Senegal?

Few studies to date have determined the effect of provider bias based on age, parity, and marital status on women's method and facility choice. Using data from women using modern methods in six cities of Senegal and a facility survey that included a facility audit and provider interviews, we undertake conditional logit analyses to determine whether women's choice of a family planning facility is associated with provider bias at the facility, controlling for other facility characteristics (e.g., size, sector, and number of methods available). We find that women bypass facilities where there is greater provider bias to attain their current family planning method. Women also bypass facilities of lower quality. This is the first study to demonstrate the effects of provider bias on women's contraceptive seeking behaviors and suggests the importance of training providers to reduce age and parity bias that affect access to a full range of methods and facilities for all women.

The direct and indirect effects of community beliefs and attitudes on postpartum contraceptive method choice among young women ages 15-24 in Nigeria.

Understanding what factors influence postpartum contraceptive use among young people (ages 15-24 years) is important since this group often has closely spaced and unintended births. Using secondary data gathered for an evaluation of a Bill & Melinda Gates Foundation funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria, we determine the direct and indirect effects of community beliefs and attitudes on adolescent and youth postpartum contraceptive method choice. Our statistical methods control for the endogenous timing of the initiation of sexual activity and the timing and number of births to each respondent by simultaneous estimation of equations for these choices with the choice of postpartum contraceptive method. We find that community beliefs and attitudes have important effects on our primary outcome of postpartum contraceptive use and we quantify the size of both direct and indirect effects on postpartum contraceptive method choice using simulations. The findings from this study can be used to inform programs seeking to increase young women's postpartum contraceptive use for healthy spacing and timing of births.