Validation and Predictive Utility of a Person-Centered Quality of Contraceptive Counseling (QCC-10) Scale in Sub-Saharan Africa: A Multicountry Study of Family Planning Clients and a New Indicator for Measuring High-Quality, Rights-Based Care.

The lack of validated, cross-cultural measures for examining quality of contraceptive counseling compromises progress toward improved services. We tested the validity and reliability of the 10-item Quality of Contraceptive Counseling scale (QCC-10) and its association with continued protection from unintended pregnancy and person-centered outcomes using longitudinal data from women aged 15-49 in Burkina Faso, Kenya, and Nigeria. Psychometric analysis showed moderate-to-strong reliability (alphas: 0.73-0.91) and high convergent validity with greatest service satisfaction. At follow-up, QCC-10 scores were not associated with continued pregnancy protection but were linked to contraceptive informational needs being met among Burkinabe and Kenyan women; the reverse was true in Kano. Higher QCC-10 scores were also associated with care-seeking among Kenyan women experiencing side effects. The QCC-10 is a validated scale for assessing quality of contraceptive counseling across diverse contexts. Future work is needed to improve understanding of how the QCC-10 relates to person-centered measures of reproductive health.

Reconceptualizing Measurement of Emergency Contraceptive Use: Comparison of Approaches to Estimate the Use of Emergency Contraception.

Estimated use of emergency contraception (EC) remains low, and one reason is measurement challenges. The study aims to compare EC use estimates using five approaches. Data come from Performance Monitoring and Accountability 2020 surveys from 10 countries, representative sample surveys of women aged 15 to 49 years. We explore EC use employing the five definitions and calculate absolute differences between a reference definition (percentage of women currently using EC as the most effective method) and each of the subsequent four, including the most inclusive (percentage of women having used EC in the past year). Across the 17 geographies, estimated use varies greatly by definition and EC use employing the most inclusive definition is statistically significantly higher than the reference estimate. Impact of using various definitions is most pronounced among unmarried sexually active women. The conventional definition of EC use likely underestimates the magnitude of EC use, which has unique programmatic implications.

Estimates of Side Effects Counseling in Family Planning Using Three Data Sources: Implications for Monitoring and Survey Design.

With growing attention to monitoring and improving quality of care, it is critical to have evidence-based recommendations to measure quality of care indicators and guidelines to interpret estimates from different data sources. This study facilitates methodological discussion regarding measurement of counseling for side effects in family planning, a critical component of quality. The study assesses and compares estimates of side effects counseling based on three data sources. Data came from nationally representative facility and household surveys, Service Provision Assessments, and Demographic and Health Surveys in four countries. The level of side effects counseling was unacceptably low and varied systematically by data source. Compared to observation data in the facility survey, exit interview data from the survey overestimated the level substantially, and its reporting had poor predictive value. Estimates from household surveys were comparable with the observation-based estimates applying the minimum definition of counseling. In monitoring quality of care, data sources should be carefully reviewed, and estimates may need to be adjusted if the sources are inconsistent.

Measuring Access to Family Planning: Conceptual Frameworks and DHS Data.

Expanding access to family planning (FP) is a driving aim of global and national FP efforts. The definition and measurement of access, however, remain nebulous, largely due to complexity. This article aims to bring clarity to the measurement of FP access. First, we synthesize key access elements for measurement by reviewing three well-known frameworks. We then assess the extent to which the Demographic and Health Surveys (DHS)-a widely used data source for FP programs and research-has information to measure these elements. We finally examine barriers to access by element, using the latest DHS data from four countries in sub-Saharan Africa. We discuss opportunities and limitations in the measurement of access, the importance of careful interpretation of data from population-based surveys, and recommendations for collecting and using data to better measure access.

Comparison of medicine availability measurements at health facilities: evidence from Service Provision Assessment surveys in five sub-Saharan African countries.

BACKGROUND: With growing emphasis on health systems strengthening in global health, various health facility assessment methods have been used increasingly to measure medicine and commodity availability. However, few studies have systematically compared estimates of availability based on different definitions. The objective of this study was to compare estimates of medicine availability based on different definitions. METHODS: A secondary data analysis was conducted using data from the Service Provision Assessment (SPA)--a nationally representative sample survey of health facilities--conducted in five countries: Kenya SPA 2010, Namibia SPA 2009, Rwanda SPA 2007, Tanzania SPA 2006, and Uganda SPA 2007. For 32 medicines, percent of facilities having the medicine were estimated using five definitions: four for current availability and one for six-month period availability. 'Observed availability of at least one valid unit' was used as a reference definition, and ratios between the reference and each of the other four estimates were calculated. Summary statistics of the ratios among the 32 medicines were calculated by country. The ratios were compared further between public and non-public facilities within each country. RESULTS: Across five countries, compared to current observed availability of at least one valid unit, 'reported availability without observation' was on average 6% higher (ranging from 3% in Rwanda to 8% in Namibia), 'observed availability where all units were valid' was 11% lower (ranging from 2% in Tanzania to 19% in Uganda), and 'six-month period availability' was 14% lower (ranging from 5% in Namibia to 25% in Uganda). CONCLUSIONS: Medicine availability estimates vary substantially across definitions, and need to be interpreted with careful consideration of the methods used.

A systematic review of Demographic and Health Surveys: data availability and utilization for research.

OBJECTIVE: To systematically review the public health literature to assess trends in the use of Demographic and Health Survey (DHS) data for research from 1984 to 2010 and to describe the relationship between data availability and data utilization. METHODS: The MEASURE DHS web site was searched for information on all population-based surveys completed under the DHS project between 1984 and 2010. The information collected included the country, type of survey, survey design, fieldwork period and certain special features, such as inclusion of biomarkers. A search of PubMed was also conducted to identify peer-reviewed articles published during 2010 that analysed DHS data and included an English-language abstract. Trends in data availability and in the use of DHS data for research were assessed through descriptive, graphical and bivariate linear regression analyses. FINDINGS: In total, 236 household surveys under the DHS project were completed across 84 countries during 2010. The number of surveys per year has remained constant, although the scope of the survey questions has expanded. The inclusion criteria were met by 1117 peer-reviewed publications. The number of publications has increased progressively over the last quarter century, with an average annual increment of 4.3 (95% confidence interval, CI: 3.2-5.3) publications. Trends in the number of peer-reviewed publications based on the use of DHS data were highly correlated with trends in funding for health by the Government of the United States of America and globally. CONCLUSION: Published peer-reviewed articles analysing DHS data, which have increased progressively in number over the last quarter century, have made a substantial contribution to the public health evidence base in developing countries.

Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh.

BACKGROUND: Lack of data is a critical barrier to addressing the problem of stillbirth in countries with the highest stillbirth burden. Our study objective was to estimate the levels, types, and causes of stillbirth in rural Sylhet district of Bangladesh. METHODS: A complete pregnancy history was taken from all women (n=39 998) who had pregnancy outcomes during 2003-2005 in the study area. Verbal autopsy data were obtained for all identified stillbirths during the period. We used pre-defined case definitions and computer programs to assign causes of stillbirth for selected causes containing specific signs and symptoms. Both non-hierarchical and hierarchical approaches were used to assign causes of stillbirths. RESULTS: A total of 1748 stillbirths were recorded during 2003-2005 from 48,192 births (stillbirth rate: 36.3 per 1000 total births). About 60% and 40% of stillbirths were categorized as antepartum and intrapartum, respectively. Maternal conditions, including infections, hypertensive disorders, and anemia, contributed to about 29% of total antepartum stillbirths. About 50% of intrapartum stillbirths were attributed to obstetric complications. Maternal infections and hypertensive disorders contributed to another 11% of stillbirths. A cause could not be assigned in nearly half (49%) of stillbirths. CONCLUSION: The stillbirth rate is high in rural Bangladesh. Based on algorithmic approaches using verbal autopsy data, a substantial portion of stillbirths is attributable to maternal conditions and obstetric complications. Programs need to deliver community-level interventions to prevent and manage maternal complications, and to develop strategies to improve access to emergency obstetric care. Improvements in care to avert stillbirth can be accomplished in the context of existing maternal and child health programs. Methodological improvements in the measurement of stillbirths, especially causes of stillbirths, are also needed to better define the burden of stillbirths in low-resource settings.

Health system performance at the district level in Indonesia after decentralization.

BACKGROUND: Assessments over the last two decades have showed an overall low level of performance of the health system in Indonesia with wide variation between districts. The reasons advanced for these low levels of performance include the low level of public funding for health and the lack of discretion for health system managers at the district level. When, in 2001, Indonesia implemented a radical decentralization and significantly increased the central transfer of funds to district governments it was widely expected that the performance of the health system would improve. This paper assesses the extent to which the performance of the health system has improved since decentralization. METHODS: We measured a set of indicators relevant to assessing changes in performance of the health system between two surveys in three areas: utilization of maternal antenatal and delivery care; immunization coverage; and contraceptive source and use. We also measured respondents' demographic characteristics and their living circumstances. These measurements were made in population-based surveys in 10 districts in 2002-03 and repeated in 2007 in the same 10 districts using the same instruments and sampling methods. RESULTS: The dominant providers of maternal and child health in these 10 districts are in the private sector. There was a significant decrease in birth deliveries at home, and a corresponding increase in deliveries in health facilities in 5 of the 10 districts, largely due to increased use of private facilities with little change in the already low use of public facilities. Overall, there was no improvement in vaccination of mothers and their children. Of those using modern contraceptive methods, the majority obtained them from the private sector in all districts. CONCLUSIONS: There has been little improvement in the performance of the health system since decentralization occurred in 2001 even though there have also been significant increases in public funding for health. In fact, the decentralization has been limited in extent and structural problems make management of the system as a whole difficult. At the national level there has been no real attempt to envision the health system that Indonesia will need for the next 20 to 30 years or how the substantial public subsidy to this lightly regulated private system could be used in creative ways to stimulate innovation, mitigate market failures, improve equity and quality, and to enhance the performance of the system as a whole.

Racial-ethnic disparities in case fatality ratio narrowed after age standardization: A call for race-ethnicity-specific age distributions in State COVID-19 data.

Importance: COVID-19 racial disparities have gained significant attention yet little is known about how age distributions obscure racial-ethnic disparities in COVID-19 case fatality ratios (CFR). Objective: We filled this gap by assessing relevant data availability and quality across states, and in states with available data, investigating how racial-ethnic disparities in CFR changed after age adjustment. Design/Setting/Participants/Exposure: We conducted a landscape analysis as of July 1st, 2020 and developed a grading system to assess COVID-19 case and death data by age and race in 50 states and DC. In states where age- and race-specific data were available, we applied direct age standardization to compare CFR across race-ethnicities. We developed an online dashboard to automatically and continuously update our results. Main Outcome and Measure: Our main outcome was CFR (deaths per 100 confirmed cases). We examined CFR by age and race-ethnicities. Results: We found substantial variations in disaggregating and reporting case and death data across states. Only three states, California, Illinois and Ohio, had sufficient age- and race-ethnicity-disaggregation to allow the investigation of racial-ethnic disparities in CFR while controlling for age. In total, we analyzed 391,991confirmed cases and 17,612 confirmed deaths. The crude CFRs varied from, e.g. 7.35% among Non-Hispanic (NH) White population to 1.39% among Hispanic population in Ohio. After age standardization, racial-ethnic differences in CFR narrowed, e.g. from 5.28% among NH White population to 3.79% among NH Asian population in Ohio, or an over one-fold difference. In addition, the ranking of race-ethnic-specific CFRs changed after age standardization. NH White population had the leading crude CFRs whereas NH Black and NH Asian population had the leading and second leading age-adjusted CFRs respectively in two of the three states. Hispanic population's age-adjusted CFR were substantially higher than the crude. Sensitivity analysis did not change these results qualitatively. Conclusions and Relevance: The availability and quality of age- and race-ethnic-specific COVID-19 case and death data varied greatly across states. Age distributions in confirmed cases obscured racial-ethnic disparities in COVID-19 CFR. Age standardization narrows racial-ethnic disparities and changes ranking. Public COVID-19 data availability, quality, and harmonization need improvement to address racial disparities in this pandemic.

Improving the demand for birth registration: a discrete choice experiment in Ethiopia.

INTRODUCTION: Birth registration remains limited in most low and middle-income countries. We investigated which characteristics of birth registration facilities might determine caregivers' decisions to register children in Ethiopia. METHODS: We conducted a discrete choice experiment in randomly selected households in Addis Ababa and the Southern Nations, Nationalities, and People's Region. We interviewed caregivers of children 0-5 years old. We asked participants to make eight choices between pairs of hypothetical registration facilities. These facilities were characterised by six attributes selected through a literature review and consultations with local stakeholders. Levels of these attributes were assigned at random using a fractional design. We analysed the choice data using mixed logit models that account for heterogeneity in preferences across respondents. We calculated respondents' willingness to pay to access registration facilities with specific attributes. We analysed all data separately by place of residence (urban vs rural). RESULTS: Seven hundred and five respondents made 5614 choices. They exhibited preferences for registration facilities that charged lower fees for birth certificates, that required shorter waiting time to complete procedures and that were located closer to their residence. Respondents preferred registration facilities that were open on weekends, and where they could complete procedures in a single visit. In urban areas, respondents also favoured registration facilities that remained open for extended hours on weekdays, and where the presence of only one of the parents was required for registration. There was significant heterogeneity between respondents in the utility derived from several attributes of registration facilities. Willingness to pay for access to registration facilities with particular attributes was larger in urban than rural areas. CONCLUSION: In these regions of Ethiopia, changes to the operating schedule of registration facilities and to application procedures might help improve registration rates. Discrete choice experiments can help orient initiatives aimed at improving birth registration.

Automated and Interviewer-Administered Mobile Phone Surveys in Burkina Faso: Sociodemographic Differences Among Female Mobile Phone Survey Respondents and Nonrespondents.

BACKGROUND: The remarkable growth of cell phone ownership in low- and middle-income countries has generated significant interest in using cell phones for conducting surveys through computer-assisted telephone interviews, live interviewer-administered surveys, or automated surveys (ie, interactive voice response). OBJECTIVE: This study aimed to compare, by mode, the sociodemographic characteristics of cell phone owners who completed a follow-up phone survey with those who did not complete the survey. METHODS: The study was based on a nationally representative sample of women aged 15 to 49 years who reported cell phone ownership during a household survey in Burkina Faso in 2016. Female cell phone owners were randomized to participate in a computer-assisted telephone interview or hybrid interactive voice response follow-up phone survey 11 months after baseline interviews. Completion of the phone survey was defined as participants responding to more than 50% of questions in the phone survey. We investigated sociodemographic characteristics associated with cell phone survey completion using multivariable logistic regression models, stratifying the analysis by survey mode and by directly comparing computer-assisted telephone interview and hybrid interactive voice response respondents. RESULTS: A total of 1766 women were called for the phone survey between November 5 and 17, 2017. In both the computer-assisted telephone interview and hybrid interactive voice response samples, women in urban communities and women with secondary education or higher were more likely to complete the survey than their rural and less-educated counterparts. Compared directly, women who completed the hybrid interactive voice response survey had higher odds of having a secondary education than those who completed computer-assisted telephone interviews (odds ratio 1.7, 95% CI 1.1-2.6). CONCLUSIONS: In Burkina Faso, computer-assisted telephone interviews are the preferred method of conducting cell phone surveys owing to less sample distortion and a higher response rate compared with a hybrid interactive voice response survey.

Validation of community health workers' assessment of neonatal illness in rural Bangladesh.

OBJECTIVE: To estimate the validity (sensitivity, specificity, and positive and negative predictive values) of a clinical algorithm as used by community health workers (CHWs) to detect and classify neonatal illness during routine household visits in rural Bangladesh. METHODS: CHWs evaluated breastfeeding and symptoms and signs of illness in 395 neonates selected randomly from neonatal illness surveillance during household visits on postnatal days 0, 2, 5 and 8. Neonates classified with very severe disease (VSD) were referred to a community-based hospital. Within 12 hours of CHW assessments, physicians independently evaluated all neonates seen in a given day by one CHW, randomly chosen from among 36 project CHWs. Physicians recorded symptoms and signs of illness, classified the illness, and determined whether the newborn needed referral-level care at the hospital. Physicians' identification and classification were used as the gold standard in determining the validity of CHWs' identification of symptoms and signs of illness and its classification. FINDINGS: CHWs' classification of VSD showed a sensitivity of 73%, a specificity of 98%, a positive predictive value of 57% and a negative predictive value of 99%. A maternal report of any feeding problem as ascertained by physician questioning was significantly associated (P < 0.001) with 'not sucking at all' and 'not attached at all' or 'not well attached' as determined clinically by CHWs during feeding assessment. CONCLUSION: CHWs identified with high validity the neonates with severe illness needing referral-level care. Home-based illness recognition and management, including referral of neonates with severe illness by CHWs, is a promising strategy for improving neonatal health and survival in low-resource developing country settings.

Reporting sterilization as a current contraceptive method among sterilized women: lessons learned from a population with high sterilization rates, Rajasthan, India.

OBJECTIVE: Measuring current use of contraception relies on self-reported responses from survey respondents. Reporting validity may be affected by women's interpretation of the question and may vary by background characteristics of women. The study aims to understand levels and patterns of underreporting of female sterilization in a population with high sterilization rates. STUDY DESIGN: Data came from the Performance Monitoring and Accountability 2020 survey conducted in Rajasthan, India, in early 2017. In addition to a conventional question to ascertain current contraceptive use, the survey included a probing question; women who did not report sterilization as a current method were asked if they were ever sterilized. Women were defined as sterilization users based on either question. Among sterilized women, we estimated the percent who reported sterilization as a current method. Multivariable logistic regression analysis was conducted to assess differential reporting across background characteristics. RESULTS: Among women who were ever sterilized, 78% reported currently using any contraceptive method(s), and 77% reported sterilization as the current method. Women in the lowest household wealth quintile or in general caste were less likely to report sterilization as a current method. Time since sterilization was not associated with correct reporting of sterilization. CONCLUSION: This study demonstrates, in a population with high sterilization, that sterilization as a current contraceptive method would be substantially underestimated using conventional survey questions. It highlights the importance of context-specific questionnaire adaptation to measure and monitor contraceptive use and provides implications in measuring current use of contraception in populations with high rates of sterilization. IMPLICATIONS: The paper examined reporting of sterilization as a current method among sterilized women. Only 77% of sterilized women reported sterilization as a current contraceptive method. In a population with high sterilization, inclusion of a probe question in surveys is recommended to understand reporting quality and accurately measure contraceptive prevalence rates.

Cell phone ownership and modern contraceptive use in Burkina Faso: implications for research and interventions using mobile technology.

OBJECTIVES: With over 420 million unique cell phone subscribers in sub-Saharan Africa, the opportunities to use personal cell phones for public health research and interventions are increasing. We assess the association between cell phone ownership and modern contraceptive use among women in Burkina Faso to understand the opportunity to track family planning indicators using cell phone surveys or provide family planning interventions remotely. STUDY DESIGN: We analyzed data from a cross-sectional, nationally representative population-based survey of women of reproductive age in Burkina Faso, the Performance Monitoring and Accountability 2020 Round 4, which was conducted between November 2016 and January 2017. RESULTS: Among the 3215 female respondents aged 15 to 49 years, 47% reported cell phone ownership. Overall, 22% of women reported current modern contraceptive use. Women who owned a cell phone were more likely to report modern contraceptive use than those who did not (29% versus 15%). Adjusted for covariates (age, wealth, education, area of residence and marital status), the odds of reporting modern contraceptive use were 68% higher among cell phone owners compared to nonowners (odds ratio=1.68, 95% confidence interval 1.3-2.1). Method mix was substantially more diverse among those who owned cell phones compared to their counterparts. CONCLUSIONS: The study shows that cell phone ownership is significantly associated with modern contraceptive use in Burkina Faso, even after adjusting for women's sociodemographic characteristics. These results suggest that cell phone ownership selectivity and associated biases need to be addressed when planning family planning programs or conducting surveys using cell phones. IMPLICATIONS: Cell phones can be used for myriad family planning purposes, from confidential data collection to contraceptive promotion and knowledge dissemination, but ownership bias is significant. A cell-phone-based intervention or population-based survey is unlikely to reach a critical mass of the population at highest risk for unintended pregnancy.

Trends in contraceptive prevalence rates in sub-Saharan Africa since the 2012 London Summit on Family Planning: results from repeated cross-sectional surveys.

BACKGROUND: The Family Planning 2020 (FP2020) initiative, launched at the 2012 London Summit on Family Planning, aims to enable 120 million additional women to use modern contraceptive methods by 2020 in the world's 69 poorest countries. It will require almost doubling the pre-2012 annual growth rate of modern contraceptive prevalence rates from an estimated 0·7 to 1·4 percentage points to achieve the goal. We examined the post-Summit trends in modern contraceptive prevalence rates in nine settings in eight sub-Saharan African countries (Burkina Faso; Kinshasa, DR Congo; Ethiopia; Ghana; Kenya; Niamey, Niger; Kaduna, Nigeria; Lagos, Nigeria; and Uganda). These settings represent almost 73% of the population of the 18 initial FP2020 commitment countries in the region. METHODS: We used data from 45 rounds of the Performance Monitoring and Accountability 2020 (PMA2020) surveys, which were all undertaken after 2012, to ascertain the trends in modern contraceptive prevalence rates among all women aged 15-49 years and all similarly aged women who were married or cohabitating. The analyses were done at the national level in five countries (Burkina Faso, Ethiopia, Ghana, Kenya, and Uganda) and in selected high populous regions for three countries (DR Congo, Niger, and Nigeria). We included the following as modern contraceptive methods: oral pills, intrauterine devices, injectables, male and female sterilisations, implants, condom, lactational amenorrhea method, vaginal barrier methods, emergency contraception, and standard days method. We fitted design-based linear and quadratic logistic regression models and estimated the annual rate of changes in modern contraceptive prevalence rates for each country setting from the average marginal effects of the fitted models (expressed in absolute percentage points). Additionally, we did a random-effects meta-analysis to summarise the overall results for the PMA2020 countries. FINDINGS: The annual rates of changes in modern contraceptive prevalence rates among all women of reproductive age (15-49 years) varied from as low as 0·77 percentage points (95% CI -0·73 to 2·28) in Lagos, Nigeria, to 3·64 percentage points (2·81 to 4·47) in Ghana, according to the quadratic model. The rate of change was also high (>1·4 percentage points) in Burkina Faso, Kinshasa (DR Congo), Kaduna (Nigeria), and Uganda. Although contraceptive use was rising rapidly in Ethiopia during the pre-Summit period, our results suggested that the yearly growth rate stalled recently (0·92 percentage points, 95% CI -0·23 to 2·07) according to the linear model. From the meta-analysis, the overall weighted average annual rate of change in modern contraceptive prevalence rates in all women across all nine settings was 1·92 percentage points (95% CI 1·14 to 2·70). Among married or cohabitating women, the annual rates of change were higher in most settings, and the overall weighted average was 2·25 percentage points (95% CI 1·37-3·13). INTERPRETATIONS: Overall, the annual growth rates exceeded the 1·4 percentage points needed to achieve the FP2020 goal of 120 million additional users of modern contraceptives by 2020 in the select study settings. Local programme experiences can be studied for lessons to be shared with other countries aiming to respond to unmet demands for family planning. The findings of this study have implications for the way progress is tracked toward achieving the FP2020 goal. FUNDING: The Bill & Melinda Gates Foundation.

Simplified age-weight mortality risk classification for very low birth weight infants in low-resource settings.

OBJECTIVE: To identify a valid neonatal mortality risk prediction score feasible for use in developing countries. STUDY DESIGN: Retrospective study of 467 neonates, < or =1500 g, enrolled in trials during 1998 to 2005 at tertiary care children's hospitals in Dhaka, Bangladesh, and Cairo, Egypt, and a community field site in Sarlahi District, Nepal. We derived simplified mortality risk scores and compared their predictive accuracy with the modified Clinical Risk Index for Babies (CRIB) II. Outcome was death during hospital stay (Dhaka and Cairo) or end of the neonatal period (Nepal). RESULTS: The area under the curve receiver operating characteristic was 0.62, 0.71, 0.68, and 0.69 on the basis of the (a) CRIB II applied to the Dhaka-Cairo dataset; (b) an 18-category, simplified age, weight, sex score; (c) a binary-risk simplified age-weight (SAW) classification derived from the Dhaka-Cairo dataset; and (d) external validation of the binary-risk SAW classification in the Nepal dataset, respectively. Mortality risk prediction with the SAW classification on the basis of gestational age (< or =29 weeks) or weight (<1000 g) was improved (P = .048) compared with CRIB II. CONCLUSIONS: The SAW classification is a markedly simplified mortality risk prediction score for use in identifying high-risk, very low birth weight neonates in developing country settings for whom urgent referral is indicated.

Monitoring Progress in Equality for the Sustainable Development Goals: A Case Study of Meeting Demand for Family Planning.

OBJECTIVES: Equality is a central component of the Sustainable Development Goals (SDGs). We took one SDG indicator and benchmark-percent of family planning demand met with modern contraceptives, with a benchmark of at least 75% in all countries-as a case study to illuminate recommendations for monitoring equality. Specifically, we assessed levels, patterns, and trends in disparity by key background characteristics and identified disparity measures that are programmatically relevant and easy to interpret. METHODS: Data were from the Demographic and Health Surveys in 55 countries that have conducted at least 2 surveys since 1990. We calculated absolute difference among subgroups, disaggregated by age, education, household wealth quintile, urban/rural residence, subnational region/administrative unit, and marital status. Our unit of analysis was survey, and we conducted largely descriptive analyses. To understand trends in disparity, we used a fixed-effect linear regression model to estimate an annual rate of change in absolute differences. RESULTS: A significant level of disparity existed across various background characteristics, ranging from a median difference of 5 percentage points by marital status to 32 percentage points by administrative unit. On average across the study countries, national level of met demand has increased over time while disparity has declined in most disaggregates including by education, wealth, residence, and age. We found statistically significant positive correlations among 4 disparity measures-education, wealth, residence, and administrative unit. Disparities by wealth quintile were easiest to interpret over time and across countries. CONCLUSIONS: At the global level, we recommend monitoring disparity in met demand by wealth quintile, which is strongly correlated with disparity by education, residence, and region and comparable across countries and over time. For monitoring by individual countries and for programmatic purposes, we further recommend monitoring disparity by first-level administrative unit, which can provide direct programmatic relevance.

Legal but limited? Abortion service availability and readiness assessment in Nepal.

The government of Nepal revised its law in 2002 to allow women to terminate a pregnancy up to 12 weeks gestation for any indication on request, and up to 18 weeks if certain conditions are met. We evaluated the readiness of facilities in Nepal to provide three abortion services, manual vacuum aspiration (MVA), medication abortion (MA) and post-abortion care (PAC), using the service availability and readiness assessment (SARA) framework. The framework consists broadly of three domains; service availability, general service readiness and service readiness specific to individual services (i.e. service-specific readiness). We applied the framework to data from the Nepal Health Facility Survey 2015, a nationally representative survey of 992 health facilities. Overall, we find that access to safe abortion remains limited in Nepal. Of the facilities that reported offering delivery services and were thus eligible to provide safe abortion services, 44.5, 36.0 and 25.6% had provided any MVA, MA or PAC services, respectively, in the 3 months prior to the survey, and <2% were 'ready' to provide any abortion service based on our application of the SARA criteria for service-specific readiness. Among only the facilities that reported providing an abortion service in the 3 months prior to the survey, 3.2% of facilities that provided MVA, 1.5% of facilities that provided MA and 1.1% of the facilities that provided PAC had all the components of care required. Although the private sector conducted approximately half of all abortion services provided in the 3 months prior to the survey, no private sector facilities had all the abortion service-specific readiness components. Results suggest that accessing safe abortion services remains a significant challenge for Nepalese women, despite a set of permissive laws.

The demographic impact and development benefits of meeting demand for family planning with modern contraceptive methods.

BACKGROUND: Meeting demand for family planning can facilitate progress towards all major themes of the United Nations Sustainable Development Goals (SDGs): people, planet, prosperity, peace, and partnership. Many policymakers have embraced a benchmark goal that at least 75% of the demand for family planning in all countries be satisfied with modern contraceptive methods by the year 2030. OBJECTIVE: This study examines the demographic impact (and development implications) of achieving the 75% benchmark in 13 developing countries that are expected to be the furthest from achieving that benchmark. METHODS: Estimation of the demographic impact of achieving the 75% benchmark requires three steps in each country: 1) translate contraceptive prevalence assumptions (with and without intervention) into future fertility levels based on biometric models, 2) incorporate each pair of fertility assumptions into separate population projections, and 3) compare the demographic differences between the two population projections. Data are drawn from the United Nations, the US Census Bureau, and Demographic and Health Surveys. RESULTS: The demographic impact of meeting the 75% benchmark is examined via projected differences in fertility rates (average expected births per woman's reproductive lifetime), total population, growth rates, age structure, and youth dependency. On average, meeting the benchmark would imply a 16 percentage point increase in modern contraceptive prevalence by 2030 and a 20% decline in youth dependency, which portends a potential demographic dividend to spur economic growth. CONCLUSIONS: Improvements in meeting the demand for family planning with modern contraceptive methods can bring substantial benefits to developing countries. To our knowledge, this is the first study to show formally how such improvements can alter population size and age structure. Declines in youth dependency portend a demographic dividend, an added bonus to the already well-known benefits of meeting existing demands for family planning.