Share of current unmet need for modern contraceptive methods attributed to past users of these methods in India.

Despite persistent efforts, unmet need for contraceptives in India has declined only slightly from 14% to 13% between 2005-06 and 2015-16. Many women using a family planning method discontinue it without switching to another method and continue to have unmet need. This study quantified the share of current unmet need for modern contraceptive methods attributed to past users of these methods in India. Data were drawn from two rounds of the National Family Health Survey conducted in 2005-06 and 2015-16. Using information on women with current unmet need, and whether they used any modern method in the past, the share of past users with current unmet need for modern methods was calculated. Bivariate and multivariate analyses were performed. Among 46 million women with unmet need, 11 million were past users of modern methods in 2015-16. The share of current unmet need attributed to past users of modern contraceptive methods declined from 27% in 2005-06 to 24% in 2015-16. Share of current unmet need attributed to past users was associated with reversible method use. This share rose with increased use of modern reversible methods. With the Indian family planning programme's focus on increasing modern reversible method use, the share of unmet need attributed to past users of modern methods is likely to increase in the future. The programme's emphasis on continuation of contraceptive use, along with bringing in new users, could be one of the key strategies for India to achieve the FP2020 goals.

Health workers' outreach and intention to use contraceptives among married women in India.

BACKGROUND: The influence of health workers on uptake of maternal healthcare services is well documented; however, their outreach for family planning (FP) services and influence on the intention to use contraceptives is less explored in the Indian context. This study examined the extent of health worker outreach for FP service and its effects on intention to use contraceptives among currently married women aged 15-49 years. METHODS: This study used data from two rounds of the National Family Health Survey (NFHS) of India, conducted during 2005-06 and 2015-16 respectively. Bivariate analysis and multivariate logistic regression were used to understand the level of and change in health worker outreach for FP services over time, and its association with intention to use contraceptives among currently married women. RESULTS: In the past 10 years, health workers' outreach for FP service has significantly increased by about 10 percentage points, although the level is not optimal and only 28% of non-users were reached by health workers in 2015-16. Increase in the outreach to younger and low parity women was higher than their respective counterparts. Intention to use contraceptive among women who were not using any method was 41% when health workers contacted and discussed FP, compared to only 20% when there was no such contact with health workers. Multivariable analysis suggests that contact with health workers has significant positive effects on intention to use contraceptive (AOR = 3.05; p < 0.001; 95% CI 2.85-3.27). CONCLUSION: Increased scope of outreach of frontline health workers to provide FP communication and services will not only help in building knowledge of contraceptive methods but will also increase women's intention to use a method. For India, this may be the most promising way to achieve the Sustainable Development Goals 3.7, which calls for universal access to reproductive health services.

Reproductive efficiency in the developing world.

This study proposes a measure of reproductive losses starting from conception to age 15 as an assessment of childbearing 'efficiency'. It is suggested that losses are due to miscarriages, abortions, stillbirths and deaths to age 15. Data were drawn from various sources for seven regions embracing 129 developing countries. Mortality is an important loss in severely disadvantaged regions, especially in sub-Saharan Africa, but the abortion rates are lower there. This is reversed in the more advanced regions, where mortality is low but abortion rates are higher. Total losses numerically depend upon the rates in combination with the numbers of conceptions. The general 'efficiency' in moving from conception to a surviving child aged 15 was estimated. The abortion component of wastage has apparently not improved over time, but the mortality component has done so. Abortion rates are found to drive reproductive efficiency downwards; but efficiency is positively correlated with contraceptive use once abortion is controlled for. This implies that as efficiency is improved more couples gain confidence to turn to contraceptive use to avoid unplanned pregnancies and births.

Do Indian women receive adequate information about contraception?

This study analysed the recent changes and patterns of information received about contraceptive methods by contraceptive users in India - an important indicator of quality of care in family planning services. Data were taken from the third and fourth rounds of National Family and Health Surveys (NFHS) conducted in India during 2005-06 and 2015-16. The Method Information Index (MII) was used to capture the information received by respondents on three aspects of contraceptive method use: information about the side-effects of the method, what to do if they experienced any complication from using the method and information received about other methods of contraception. A separate analysis of information received by users about the permanency of sterilization was also carried out. Logistic regression models were applied to assess the independent effects of users' background characteristics and their states and union territories of residence on method information received by them. The value of the MII nearly doubled from about 16% in 2004-05 to 31% in 2015-16, indicating a marked increase in the information received by contraceptive users in India over the period between 2005-06 and 2015-16. In addition, the percentage of sterilized women who received information about the permanency of the method also increased, from 67% to 80%, over the period. While considerable progress has been made in the last decade, there is still plenty of scope for improvement in the information received by contraceptive users to advance a voluntary approach to family planning.

Is economic inequality in family planning in India associated with the private sector?

This study examined the pattern of economic disparity in the modern contraceptive prevalence rate (mCPR) among women receiving contraceptives from the public and private health sectors in India, using data from all four rounds of the National Family Health Survey conducted between 1992-93 and 2015-16. The mCPR was measured for currently married women aged 15-49 years. A concentration index was calculated and a pooled binary logistic regression analysis conducted to assess economic disparity (by household wealth quintiles) in modern contraceptive use between the public and private health sectors. The analyses were stratified by rural-urban place of residence. The results indicated that mCPR had increased in India over time. However, in 2015-16 only half of women - 48% (33% from the public sector, 12% from the private sector, 3% from other sources) - were using any modern contraceptive in India. Over time, the economic disparity in modern contraceptive use reduced across both public and private health sectors. However, the extent of the disparity was greater when women obtained the services from the private sector: the value of the concentration index for mCPR was 0.429 when obtained from the private sector and 0.133 when from the public sector in 2015-16. Multivariate analysis confirmed a similar pattern of the economic disparity across public and private sectors. Economic disparity in the mCPR has reduced considerably in India. While the economic disparity in 2015-16 was minimal among those accessing contraceptives from the public sector, it continued to exist among those receiving services from the private sector. While taking appropriate steps to plan and monitor private sector services for family planning, continued and increased engagement of public providers in the family planning programme in India is required to further reduce the economic disparity among those accessing contraceptive services from the private sector.

A New Composite Index to Measure National-Level Quality of Family Planning Programs.

CONTEXT: Despite efforts to use facility surveys to measure the quality of family planning programs, routine, reliable measurement and monitoring of national-level quality has not been possible. METHODS: A new composite index to measure national-level quality, the National Quality Composite Index (NQCI), is proposed and used to compare program quality in 30 developing countries. Index scores represent the unweighted average of scores from indicators of three different dimensions of quality-structure, process and outcome. The structural indicator, the Method Availability Index, used data from the 2014 Family Planning Effort survey, while the process indicator (the Method Information Index) and outcome indicator (the Method Success Index) used data from the most recent Demographic Health Surveys conducted in the included countries. Correlations between these and other indicators were examined. RESULTS: The unweighted average NQCI score for the 30 countries was 60; scores ranged from 50 in Pakistan to 72 in Cambodia. The average scores for the three NQCI components were 52 for Method Availability (range, 40-73), 41 for Method Information (range, 13-71) and 86 for Method Success (range, 70-99). Scores for these components were not correlated with each other, suggesting that they measure distinct dimensions of program quality. Overall NQCI scores were correlated with existing measures of national-level quality, but not with total fertility rate and modern contraceptive prevalence rate. CONCLUSIONS: The NQCI and its three components use data routinely collected through national surveys, and can be used to measure and monitor national-level quality of family planning programs.

RESUMEN Contexto: A pesar de los esfuerzos para utilizar encuestas de las instituciones de salud para medir la calidad de los programas de planificación familiar, no se ha podido realizar la medición y el monitoreo de la calidad de los programas a nivel nacional de manera rutinaria y confiable. Métodos: Se propone y utiliza un nuevo índice compuesto para medir la calidad a nivel nacional, el Índice Compuesto de Calidad Nacional (ICCN), con el propósito de comparar la calidad del programa de planificación familiar en 30 países en desarrollo. Los puntajes del índice representan el promedio no ponderado de los puntajes de indicadores de tres dimensiones diferentes de calidad ­estructura, proceso y resultado. El indicador de estructura, el Índice de Disponibilidad del Método, utilizó datos de la encuesta de Esfuerzo de Planificación Familiar 2014, mientras que el indicador de proceso (Índice de Información sobre el Método) y el indicador de resultados (Índice de Éxito del Método), utilizaron los datos de las encuestas demográficas de salud más recientes realizadas en los países incluidos en el estudio. Se examinaron las correlaciones entre estos y otros indicadores. Resultados: El puntaje ICCN promedio no ponderado para los 30 países fue de 60; los puntajes variaron de 50 en Pakistán a 72 en Camboya. Los puntajes promedio para los tres componentes ICCN fueron 52 para la Disponibilidad del Método (rango, 40­73), 41 para la Información sobre el Método (rango, 13­71) y 86 para el Éxito del Método (rango, 70­99). Los puntajes de estos componentes no se correlacionaron entre sí, lo que sugiere que miden distintas dimensiones de la calidad del programa. Los puntajes globales de ICCN se correlacionaron con medidas existentes de calidad a nivel nacional, pero no con la tasa de fecundidad total y la tasa de prevalencia de uso de anticonceptivos modernos. Conclusiónes: El ICCN y sus tres componentes utilizan datos recolectados rutinariamente a través de encuestas nacionales y pueden usarse para medir y monitorear la calidad a nivel nacional de los programas de planificación familiar.

RÉSUMÉ Contexte: Malgré les efforts déployés pour mesurer la qualité des programmes de planification familiale sur la base des enquêtes menées auprès des établissements, il n'a pas été possible d'assurer la mesure et le suivi réguliers et fiables de cette qualité au niveau national. Méthodes: Un nouvel indice composite de mesure de qualité au niveau national (l'indice NQCI) est proposé et utilisé pour comparer la qualité des programmes dans 30 pays en développement. Les scores d'indice représentent la moyenne non pondérée des scores d'indicateurs de trois dimensions distinctes de qualité: structure, processus et résultat. L'indicateur de structure (l'indice de disponibilité des méthodes) repose sur les données de l'enquête 2014 sur l'effort de planification familiale, tandis que l'indicateur de processus (l'indice d'information sur les méthodes) et celui de résultat (l'indice de succès des méthodes) viennent des données des dernières Enquêtes démographiques et de santé effectuées dans les pays à l'étude. Les corrélations entre ces indicateurs et d'autres ont été examinées. Résultats: Le score NQCI moyen non pondéré des 30 pays a été calculé à 60, sur une étendue comprise entre 50 au Pakistan et 72 au Cambodge. Les scores moyens des trois composants de l'indice sont 52 pour la disponibilité des méthodes (étendue 40­73), 41 pour l'information sur les méthodes (13­71) et 86 pour le succès des méthodes (70­99). Les scores de ces composants ne sont pas apparus corrélés entre eux, laissant entendre qu'ils mesurent des dimensions distinctes de la qualité des programmes. Les scores NQCI globaux étaient corrélés avec les mesures de qualité existantes au niveau national, mais pas avec l'indice synthétique de fécondité ni le taux de prévalence contraceptive moderne. Conclusions: L'indice NQCI et ses trois composants reposent sur des données collectées régulièrement à travers les enquêtes nationales; ils peuvent servir à mesurer et suivre la qualité au niveau national des programmes de planification familiale.

Revising the FP Quality of Care Framework in the Context of Rights-based Family Planning.

Nearly three decades ago, Bruce articulated a client-centered quality of care (QoC) framework for family planning services. The term quality has since then been used in many rights-based frameworks for health, reproductive health, and family planning. This commentary compares the concept of quality used in many of these frameworks to reconcile the elements of the FP QoC framework with the use of quality in various rights frameworks. We propose five modifications to the original FP QoC framework to better align it with the treatment of quality in the rights-based approaches and the way quality in family planning has been applied in practice.

Contribution of Contraceptive Discontinuation to Unintended Births in 36 Developing Countries.

High contraceptive discontinuation results in millions of women having an unmet need for contraception. However, its contribution to unintended fertility is not known. Reproductive calendar data in Demographic and Health Surveys in 36 countries are used to estimate the percent of unintended recent births attributable to contraceptive discontinuation. Contraceptive discontinuation accounted for about one-third of unintended recent births in all countries together. Method failure and contraception discontinued for other reasons accounted for most of this contribution. The contribution of contraceptive discontinuation to unintended births increases with the use of modern methods but decreases as method composition at a given level of contraceptive prevalence shifts toward methods with higher effectiveness and longer continuation. High contraceptive discontinuation in the past without changes in fertility intentions has resulted in millions of unintended births. This contribution is likely to increase with the anticipated increase in the use of modern methods. Enabling current users to reduce method failure and encouraging them to switch to another method after discontinuing the use of the original method will be an effective strategy to reduce contraceptive discontinuation and its contribution to unintended births.

INFORMATION ABOUT METHODS RECEIVED BY CONTRACEPTIVE USERS IN INDIA.

Very little is known, at national and state levels, about how much information women in India are receiving about the method of contraception they are using. The purpose of this study was to fill this gap in knowledge. A Method Information Index (MII) was calculated from the responses of women who started using a modern contraceptive method five years prior to interview, and who were still using it at the time of interview, in the third National Family Health Survey conducted in India in 2005-06. The women were asked whether at the time they initiated contraceptive use they were told about other methods they could use, the side-effects of their selected method and what to do if they experienced these side-effects. The MII values (percentages of women who responded 'yes' to all three questions) were calculated for each category of women's characteristics to show the relationship between MII and each characteristic. Mixed-effect logistic regression models were used to assess the independent effect of each variable after controlling for the effects of other variables on MII. The results indicate that contraceptive users in India in 2005-06 were receiving very little information about the method they were using: only 15.6% of contraceptive users reported receiving information on all three items. This low level was prevalent across different socioeconomic strata and across all the major states. There were a few exceptions, but the level was still quite low. Clearly, there is plenty of scope to improve the content of information exchanged between service providers and clients in order to ensure the rights of women to receive services of good quality, as well as improve informed choice and continuity of contraceptive use. Such a focus on improving quality of services is likely to help the Ministry of Health and Family Welfare in making its stated transition from a 'population control centric' to a 'reproductive rights based' approach to family planning in India.

Examining Progress and Equity in Information Received by Women Using a Modern Method in 25 Developing Countries.

CONTEXT: The information exchanged during a contraceptive visit is important because providers need to understand clients' reproductive intentions and clients need to receive adequate information about methods and possible method-related side effects and problems. Little is known about how information exchange has changed over time and how it might vary across countries or subgroups within a country. METHODS: Demographic and Health Survey data from 25 developing countries were used to calculate the Method Information Index (MII), a Family Planning 2020 indicator that reflects some aspects of contraceptive information exchanged between providers and clients. For each country, the MII was calculated from each of two surveys about five years apart to examine change in the indicator over time. In addition, the MII was examined for all countries combined and by region. RESULTS: The average MII for all 25 countries increased from 34% at the earlier survey time to 39% at the later survey time; the index values of individual countries ranged from 19% to 64% at survey time 1 and from 13% to 65% at survey time 2. The MII increased over time in 15 countries and declined in 10. In analyses by contraceptive method type, the MII tended to be highest among implant users and lowest among women relying on sterilization. The index was generally higher among women living in urban areas than among those in rural areas, and tended to rise with increases in women's education and household wealth. CONCLUSIONS: On the basis of the MII, developing countries have room to improve information exchange between providers and clients. Such improvements would require concerted efforts by programs and donors.

The constraints of distance and poverty on institutional deliveries in Pakistan: evidence from georeference-linked data.

While institutional deliveries in Pakistan have risen substantially over the last few years, the change has mainly occurred among the wealthy and those with access to services in urban areas. We assess the influence of economic and geographic access to health facilities on institutional deliveries by linking household survey data and georeferenced distance to facilities equipped to provide services for obstetric care in nine districts in Pakistan. Multilevel mixed-effect logistic regression analyses show that the net effect of an increase in distance to a facility by 1 kilometer is to decrease the odds of an institutional delivery by 3 percent. In contrast, household wealth and availability of at least basic emergency care within 10 kilometers substantially increase the odds of an institutional delivery. These effects are more pronounced in rural areas than in urban areas. Disadvantages faced by poor rural women can be minimized by upgrading existing facilities at district and subdistrict levels to provide comprehensive emergency care and by facilitating transportation of poor rural women directly to these facilities when they experience life-threatening complications of childbirth.

Aligning goals, intents, and performance indicators in family planning service delivery.

A flurry of policy initiatives in the fields of both population and development and reproductive health, many addressing the provision of family planning services, are currently underway: FP2020, the ICPD Beyond 2014, and the post-2015 development agenda, among others. This is an opportune time, therefore, to reflect upon and take into consideration what five decades of family planning programs can teach us about ensuring that policies and programs integrate their underlying intents, concrete goals, and performance indicators. The family planning field has encountered instances in its history when inconsistencies between goals, intents, and indicators arose and adversely affected the delivery of services. This commentary presents our observations concerning potential misalignments that may arise within the many promising initiatives underway. We examine the relationship between the intent, goal, and indicators of FP2020 as a case study highlighting the need for ensuring a tight alignment. We offer suggestions for ensuring that this and other initiatives use carefully calibrated indicators to guide the achievement of explicit program goals without undermining their underlying intent--namely, promoting well-being and reproductive rights.

Reducing unmet need and unwanted childbearing: evidence from a panel survey in Pakistan.

Pakistan's high unmet need for contraception and low contraceptive prevalence remain a challenge, especially in light of the country's expected contribution to the FP2020 goal of expanding family planning services to an additional 120 million women with unmet need. Analysis of panel data from 14 Pakistani districts suggests that efforts to reduce unmet need should also focus on empowering women who are currently practicing contraception to achieve their own reproductive intentions through continuation of contraceptive use of any method. Providing women with better quality of care and encouraging method switching would bridge the gap that exists when women are between methods and thus would reduce unwanted births. This finding is generalizable to other countries that, like Pakistan, are highly dependent on short-acting modern and traditional methods. The approach of preventing attrition among current contraceptive users would be at least as effective as persuading nonusers to adopt a method for the first time.

Reducing unmet need by supporting women with met need.

CONTEXT: The 2012 London Summit on family planning set a goal of providing modern contraceptives to 120 million women with unmet need by 2020. Reducing the high rate of contraceptive discontinuation by facilitating switching among methods will play a critical role in meeting that goal. METHODS: Data collected from married women in Demographic and Health Surveys conducted in 34 countries between 2005 and 2010 were used to estimate the potential contribution of contraceptive discontinuation to current and future unmet need. An indicator of relevant discontinuation was created by calculating the proportion of past users with an unmet need for modern methods among ever-users. Regression analyses identified associations between this indicator and access to and composition of methods. RESULTS: Women who had discontinued method use and subsequently had unmet need at the survey accounted for 38% of the total estimated unmet need. These past users represented 19% of women who had ever used modern methods. Both the access to and composition of available methods were associated with a reduction in the relevant discontinuation rate. The level of discontinuation in Sub-Saharan Africa was significantly higher than in other regions, in part due to differences in method availability. CONCLUSIONS: High contraceptive discontinuation in the past has contributed tens of millions of cases of unmet need, and discontinuation among current users will contribute even more cases in the future. Enabling past users with unmet need to resume use and encouraging current users to continue use of the same or another method could be an effective strategy to reduce future unmet need.

The importance of public sector health facility-level data for monitoring changes in maternal mortality risks among communities: the case of pakistan.

This paper illustrates the importance of monitoring health facility-level information to monitor changes in maternal mortality risks. The annual facility-level maternal mortality ratios (MMRs), complications to live births ratios and case fatality ratios (CFRs) were computed from data recorded during 2007 and 2009 in 31 upgraded public sector health facilities across Pakistan. The facility-level MMR declined by about 18%; both the number of Caesarean sections and the episodes of complications as a percentage of live births increased; and CFR based on Caesarean sections and episodes of complications declined by 29% and 37%, respectively. The observed increases in the proportion of women with complications among those who come to these facilities point to a reduction in the delay in reaching facilities (first and second delays; Thaddeus & Maine, 1994); the decrease in CFRs points to improvements in treating obstetric complications and a reduction in the delay in receiving treatment once at facilities (the third delay). These findings point to a decline in maternal mortality risks among communities served by these facilities. A system of woman-level data collection instituted at health facilities with comprehensive emergency obstetric care is essential to monitor changes in the effects of any reduction in the three delays and any improvement in quality of care or the effectiveness of treating pregnancy-related complications among women reaching these facilities. Such a system of information gathering at these health facilities would also help policymakers and programme mangers to measure and improve the effectiveness of safe-motherhood initiatives and to monitor progress being made toward achieving the fifth Millennium Development Goal.

The Extent and Nature of Fluidity in Typologies of Female Sex Work in Southern India: Implications for HIV Prevention Programs.

These authors examine the nature and extent of fluidity in defining the typology of female sex work based on the place of solicitation or place of sex or both places together, and whether sex workers belonging to a particular typology are at increased risk of HIV in southern India. Data are drawn from a cross-sectional survey conducted during 2007-2008 among mobile female sex workers (N = 5301) in four Indian states. Findings from this study address an important policy issue: Should programmatic prevention interventions be spread to cover all places of sex work or be focused on a few places that cover a large majority of sex workers? Results indicate that most female sex workers, including those who are usually hard to reach such as those who are mobile or who use homes for soliciting clients or sex, can be reached programmatically multiple times by concentrating on a smaller number of categories, such as street-, lodge-, and brothel-based sex workers.

Hormonal contraception and HIV acquisition risk: implications for individual users and public policies.

BACKGROUND: A recent observational study among HIV-1 serodiscordant couples (uninfected women living with an infected partner) raised concerns about the safety of injectable contraceptives, especially depot medroxyprogesterone acetate (DMPA). The purpose of this paper is to assess the implications of potentially elevated risk of Human Immunodeficiency Virus (HIV) acquisition with the use of hormonal contraceptives for individual users and public policies. STUDY DESIGN: Two indicators expressing costs (additional unwanted births and additional maternal deaths) in terms of the same unit of benefit (per 100 HIV infections averted) are estimated by using data on competing risks of unwanted birth and HIV acquisition associated with the use of various contraceptive methods. Elevated HIV acquisition risks associated with hormonal contraception observed in the observational studies of family planning users, sex workers and HIV-1 serodiscordant couples are used. Other relevant data for Kenya, South Africa and Zimbabwe are used to illustrate the potential effect of withdrawal of DMPA at the population level. RESULTS: Both the risks of unwanted birth and HIV acquisition with sterilization, intrauterine devices (IUDs) and implants at the individual level are lower than those with DMPA. A shift from DMPA to an oral contraceptive (OC) or male condom by an individual could result in about 600 and a shift to no method in about 5400 additional unwanted births per 100 HIV infections averted. At the population level, the withdrawal of DMPA from Kenya, for example, could result in 7600 annual additional unwanted births and 40 annual additional maternal deaths per 100 HIV infections averted. CONCLUSION: Individual DMPA users may be advised to shift to sterilization, IUD or implant depending upon their reproductive needs and circumstances, but not to no method, OC or even condom alone. At the macro level, the decision to withdraw DMPA from family planning programs in sub-Saharan Africa is not warranted.

Fertility differences among developing countries: are they still related to family planning program efforts and social settings?

CONTEXT: In many developing countries, fertility has declined steadily in recent decades, while the average strength of family planning programs has increased and social conditions have improved. However, it is unclear whether the synergistic effect of family planning programs and social settings on fertility, first identified in the 1970s, still holds. METHODS: Data from 40 developing countries in which Demographic and Health Surveys were conducted in 2003-2010 were used to examine associations among socioeconomic conditions, family planning program effort strength and fertility. Cross-tabulations and multiple regression analyses were conducted. RESULTS: Variation among countries in scores on the Family Planning Program Effort Index, but not on the Human Development Index, has diminished since the 1970s. On average, fertility levels were lower among countries with better social settings or stronger family planning programs than among those with poorer settings or weaker programs; they were lowest in the presence of both good social settings and strong programs. In addition, fertility was positively associated with infant mortality and negatively associated with female education, but not associated with poverty. About half of the 2.3-birth difference in fertility between countries in Sub-Saharan Africa and those elsewhere can be attributed to differences in program efforts and social settings. CONCLUSIONS: Policies focused on improving levels of female education, reducing infant mortality and improving family planning services can be expected to have mutually reinforcing effects on fertility decline.

Evaluation of an intervention to improve quality of care in family planning programme in the Philippines.

This paper presents the results of a longitudinal intervention study carried out in the Davao del Norte province of the Philippines. The intervention, tested through a quasi-experimental design, consisted of training of family planning service providers in information exchange and training of their supervisors in facilitative supervision. The training intervention significantly improved providers' knowledge and quality of care received by clients. Moreover, good quality care received by clients at the time of initiating contraception use increased the likelihood of contraceptive continuation and decreased the likelihood of both having an unintended pregnancy and an unwanted birth. However, comparison of women in the experimental group with those in the control group did not show any significant effect of provider-level training intervention on these client-level outcomes. The reasons for this conundrum and the implications for quality of care are discussed.

Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India.

This paper examines the relationship between indicators of mobility, socio-economic vulnerabilities, and HIV risk behaviours among 5,498 mobile female sex workers (FSWs) living in the four high HIV prevalence states in India. Female sex workers with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they experienced physical violence, and consumed alcohol prior to sex. Further, FSWs with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they had inconsistent condom use in sex with clients, even after controlling for several demographic characteristics and socio-economic vulnerabilities including experiences of violence. Additionally, short duration visits and visit to the Jatra (religious fairs) places found to have significant association with their inconsistent condom use in sex with clients as well as continuation of sex despite having STI symptoms. These findings suggest the need for screening FSWs for higher degree of mobility and to mobilize them to form community networks so as to deal with violence, reduce alcohol use and promote consistent condom use along the routes of mobility. HIV prevention interventions aimed at FSWs require an increased attention to address the socio-economic vulnerabilities including alcohol use, with particular emphasis on those FSWs who are on the move in India and elsewhere.