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

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

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

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

Does knowledge about antiretroviral therapy and mother-to-child transmission affect the relationships between HIV status and fertility preferences and contraceptive use? New evidence from Nigeria and Zambia.

The increasing availability of antiretroviral therapy (ART) and drug regimens to prevent mother-to-child transmission (PMTCT) has probably changed the context of childbearing for people living with HIV. Using data from 2009-2010 community-based surveys in Nigeria and Zambia, this study explores whether women's knowledge about ART and PMTCT influences the relationship between HIV status and fertility preferences and contraceptive behaviour. The findings show that women living with HIV are more likely to want more children in Nigeria and to want to limit childbearing in Zambia compared with HIV-negative women. While there is no significant difference in contraceptive use by women's HIV status in the two countries, women who did not know their HIV status are less likely to use contraceptives relative to women who are HIV-negative. Knowledge about ART reduces the childbearing desires of HIV-positive women in Nigeria and knowledge about PMTCT increases desire for more children among HIV-positive women in Zambia, as well as contraceptive use among women who do not know their HIV status. The findings indicate that knowledge about HIV prevention and treatment services changes how living with HIV affects childbearing desires and, at least in Zambia, pregnancy prevention, and highlight the importance of access to accurate knowledge about ART and PMTCT services to assist women and men to make informed childbearing decisions. Knowledge about ART and PMTCT should be promoted not only through HIV treatment and maternal and newborn care facilities but also through family planning centres and the mass media.

Setting Health Targets Using Information from Probabilistic Projections: A Research Brief on an Application to Contraceptive Coverage.

Broad and aspirational targets to meet health service needs are useful for advocacy, but setting measurable, time-defined targets for accelerated yet feasible progress is necessary for national monitoring and planning purposes. Information from probabilistic projections of health outcomes and service coverage can be used to set country-specific targets that reflect different starting points and rates of change. We show the utility of this approach in an application to contraceptive coverage in 131 low- and middle-income countries (LMICs) and the related cost and impact of different coverage scenarios. We use the sustainable development goal (SDG) indicator of the proportion of women who have their need for family planning satisfied with modern contraception. The results show that accelerated progress targets would collectively result in 83% of the need satisfied in 2030 for LMICs, which is 5% points higher than the projected level based on the current pace of progress. This translated into 41 million fewer women with an unmet need for modern methods and 14 million fewer unintended pregnancies. Annual direct costs would be $480 million more in 2030 to support contraceptive services compared with costs in 2030 based on the current pace of progress. As governments plan and budget for expanded health service coverage, information from probabilistic projections can guide them in setting measurable, ambitious yet realistic targets that are relevant to their particular contexts. Supplementary Information: The online version contains supplementary material available at 10.1007/s11113-023-09766-2.

Impacts of COVID-19 on contraceptive and abortion services in low- and middle-income countries: a scoping review.

The COVID-19 pandemic has disproportionate effects on people living in low- and middle-income countries (LMICs), exacerbating weak health systems. We conducted a scoping review to identify, map, and synthesise studies in LMICs that measured the impact of COVID-19 on demand for, provision of, and access to contraceptive and abortion-related services, and reproductive outcomes of these impacts. Using a pre-established protocol, we searched bibliographic databases (December 2019-February 2021) and key grey literature sources (December 2019-April 2021). Of 71 studies included, the majority (61%) were not peer-reviewed, and 42% were based in Africa, 35% in Asia, 17% were multi-region, and 6% were in Latin America and the Caribbean. Most studies were based on data through June 2020. The magnitude of contraceptive service-related impacts varied widely across 55 studies (24 of which also included information on abortion). Nearly all studies assessing changes over time to contraceptive service provision noted declines of varying magnitude, but severe disruptions were relatively uncommon or of limited duration. Twenty-six studies addressed the impacts of COVID-19 on abortion and postabortion care (PAC). Overall, studies found increases in demand, reductions in provision and increases in barriers to accessing these services. The use of abortion services declined, but the use of PAC was more mixed with some studies finding increases compared to pre-COVID-19 levels. The impacts of COVID-19 varied substantially, including the country context, health service, and population studied. Continued monitoring is needed to assess impacts on these key health services, as the COVID-19 pandemic evolves.

Is the internet filling the sexual health information gap for teens? An exploratory study.

At the same time that there was a decline in comprehensive school-based sex education, adolescents' use of the Internet became nearly universal. This study explores adolescents' use and evaluation of the Internet for sexual health information, with a focus on the issues of contraception and abstinence. The authors conducted 58 in-depth interviews with juniors and seniors in 3 public high schools in New York City and Indiana. Most of the adolescents used the Internet on a daily basis, but few considered it a main source of information about contraception or abstinence. Students were more likely to rely on and had greater trust in traditional sexuality education sources such as school, family members, and friends. Most of the adolescents the authors interviewed were wary of sexual health information on the Internet, and the authors describe strategies adolescents used to sort through the abundance of sex-related material. Formal and informal efforts to provide sexuality education to adolescents should include specific age- and content-appropriate Web sites because many teens are not actively searching on their own, and they express reservations about relying on the Internet as a source of sexual health information.

Social organization and the transition from direct to indirect consumption.

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

Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health In Low- and Middle-Income Countries.

The novel coronavirus (SARS-CoV-2) that causes COVID-19 has spread rapidly since emerging in late 2019, leading the World Health Organization (WHO) to declare the disease a global pandemic on March 11, 2020. Governments around the world have had to quickly adapt and respond to curb transmission of the virus and to provide care for the many who have been infected. The strain that the outbreak imposes on health systems will undoubtedly impact the sexual and reproductive health of individuals living in low- and middle-income countries (LMICs); however, sexual and reproductive health will also be affected by societal responses to the pandemic, such as local or national lockdowns that force health services to shut down if they are not deemed essential, as well as the consequences of physical distancing, travel restrictions and economic slowdowns.

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.

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions.

BACKGROUND: Abortion-related mortality is one of the main causes of maternal mortality worldwide. Laws often restrict the provision of safe abortion care, yet post-abortion care is a service that all countries have committed to provide to manage abortion complications. There is minimal evidence on the capacity of national health systems to provide post-abortion care. METHODS: We did a multicountry analysis of data from nationally representative Service Provision Assessment surveys done between 2007 to 2017 in ten countries across three regions (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). Data were available for all ten countries from 2007 to 2015. We included facilities offering childbirth delivery services and classified facilities as primary or referral level. We measured signal functions for post-abortion care (the availability of key equipment and ability to perform services) to assess the proportion of primary-level and referral-level facilities in each country with the capacity to provide basic and comprehensive post-abortion care, respectively. We calculated the proportion of facilities providing each post-abortion care signal function to examine specific gaps in service provision. FINDINGS: There are critical gaps in the provision of post-abortion care at all facilities that offer delivery services. In seven (70%) of ten countries, less than 10% of primary-level facilities could provide basic post-abortion care, and in eight (80%) of ten countries less than 40% of referral-level facilities could provide comprehensive post-abortion care. In no country could all referral facilities provide all the essential services that need to be included in basic post-abortion care. INTERPRETATION: The capacity of primary-level and referral-level health facilities to provide basic and comprehensive post-abortion care, respectively, is low. The results highlight the gap between political commitments to address the consequences of unsafe abortion and the capacity of health systems to provide post-abortion care. Increasing the provision of good-quality post-abortion care is essential to reduce the level of abortion-related morbidity and mortality. FUNDING: UK Aid from the UK Government.

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

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

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

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

Influence of social connectedness, communication and monitoring on adolescent sexual activity in Ghana.

This paper examines connectedness to, communication with and monitoring of unmarried adolescents in Ghana by parents, other adults, friends and key social institutions and the roles these groups play with respect to adolescent sexual activity. The paper draws on 2004 nationally-representative survey data and qualitative evidence from focus group discussions and in-depth interviews with adolescents in 2003. Adolescents show high levels of connectedness to family, adults, friends, school and religious groups. High levels of adult monitoring are also observed, but communication with family about sex-related matters was not as high as with non-family members. The qualitative data highlight gender differences in communication. Multivariate analysis of survey data shows a strong negative relationship between parental monitoring and recent sexual activity for males and females, and limited effects of communication. Creating a supportive environment and showing interest in the welfare of adolescents appear to promote positive sexual and reproductive health outcomes.

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

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

Induced abortion in Colombia: new estimates and change between 1989 and 2008.

CONTEXT: Although abortion was made legal in Colombia under selected circumstances in 2006, no national studies have examined whether the incidence of the procedure has changed since the previous estimate in 1989. METHODS: Data on the number of women treated for abortion complications were obtained from a nationally representative survey of 300 public and private health facilities, and estimates of the likelihood that women obtaining abortions experience complications and receive treatment at a facility were obtained from a survey of 102 knowledgeable professionals. Indirect estimation techniques were used to calculate national and regional abortion measures for 2008, which were compared with previously published 1989 estimates. Numbers and rates of unintended pregnancy were also calculated. RESULTS: In 2008, an estimated 93,300 women were treated for induced abortion complications in public and private health facilities. An estimated 400,400 induced abortions were performed, which translates to a rate of 39 per 1,000 women aged 15-44, a slight increase from 1989 (36 per 1,000). Rates varied widely across regions, from 66 in Bogotá to 18 in Oriental. Despite the new abortion law, only 322 legal abortions were performed in 2008. Between 1989 and 2008, the proportion of pregnancies ending in induced abortion increased from 22% to 29%, and the proportion of pregnancies that were unintended rose from 52% to 67%. CONCLUSION: Improvements in provision of and access to contraceptive and legal abortion services are needed to meet the increased demand among women and couples to prevent unintended pregnancy and unsafe abortion.

Women's and men's fertility preferences and contraceptive behaviors by HIV status in 10 sub-Saharan African countries.

This article draws on biomarker data from Demographic and Health Surveys (2003-2007) in 10 sub-Saharan African countries to examine differences in fertility preferences and contraceptive behaviors by HIV status for women and men, taking into account whether or not they probably know their HIV status. The objective is to determine if there are common patterns in the associations between these variables across several countries. Women's and men's fertility preferences and contraceptive behaviors are relatively similar across HIV status and probable knowledge of that status. However, two consistent differences emerge in some of the countries: HIV-positive women who probably know their status are less likely to want more children and are more likely to be using male condoms than women who are HIV-negative and probably know it. A similar association is observed for men for condom use but not for limiting childbearing. Other factors unrelated to HIV status seem to be shaping women's and men's unmet demand for contraception and use of methods other than the condom.

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

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