Provider Bias in Family Planning Services: A Review of Its Meaning and Manifestations.

Family planning programs are guided by the principle of informed choice as well as the goal of providing a broad choice of contraceptive methods to clients. Provider bias is an important barrier to realizing this goal, but it must be clearly defined and understood to be effectively addressed. This review presents an overview of the concept of provider bias in family planning, focusing on the following issues: (1) what it is, (2) how widespread it is, (3) its underlying causes, (4) its impacts, and (5) how it can be effectively addressed. The definitions of provider bias include common themes about providers creating barriers to choice, typically based on the characteristics of either a client or a contraceptive method. However, an agreed-upon definition is lacking. Measurement of provider bias has often relied on self-reports by providers but has also included observation and use of mystery clients for supplemental data. The general trend in the data is clear: large numbers of providers impose barriers and restrictions beyond those that are in guidelines or are necessary for any medical reasons. This trend indicates the presence of bias. Providers have shown bias based on age, parity, marital status, and other criteria, with a bias against provision of various contraceptive methods to youth being the most common. Provider bias often stems from broader social norms, particularly judgments about sexual activity among youth and concerns about the impact of hormonal methods on future fertility. Little documentation of the impact of provider bias exists, although method mix skew has been identified as a possible red flag for bias. Newer approaches to address bias that have moved beyond traditional training and guidelines development to more fundamental behavior change efforts show promise, and learning from their lessons will be important. A major question is how to scale up such approaches.

Jordan's 2002 to 2012 Fertility Stall and Parallel USAID Investments in Family Planning: Lessons From an Assessment to Guide Future Programming.

Health practitioners, researchers, and donors are stumped about Jordan's stalled fertility rate, which has stagnated between 3.7 and 3.5 children per woman from 2002 to 2012, above the national replacement level of 2.1. This stall paralleled United States Agency for International Development (USAID) funding investments in family planning in Jordan, triggering an assessment of USAID family planning programming in Jordan. This article describes the methods, results, and implications of the programmatic assessment. Methods included an extensive desk review of USAID programs in Jordan and 69 interviews with reproductive health stakeholders. We explored reasons for fertility stagnation in Jordan's total fertility rate (TFR) and assessed the effects of USAID programming on family planning outcomes over the same time period. The assessment results suggest that the increased use of less effective methods, in particular withdrawal and condoms, are contributing to Jordan's TFR stall. Jordan's limited method mix, combined with strong sociocultural determinants around reproduction and fertility desires, have contributed to low contraceptive effectiveness in Jordan. Over the same time period, USAID contributions toward increasing family planning access and use, largely focused on service delivery programs, were extensive. Examples of effective initiatives, among others, include task shifting of IUD insertion services to midwives due to a shortage of female physicians. However, key challenges to improved use of family planning services include limited government investments in family planning programs, influential service provider behaviors and biases that limit informed counseling and choice, pervasive strong social norms of family size and fertility, and limited availability of different contraceptive methods. In contexts where sociocultural norms and a limited method mix are the dominant barriers toward improved family planning use, increased national government investments toward synchronized service delivery and social and behavior change activities may be needed to catalyze national-level improvements in family planning outcomes.

Moving towards the goals of FP2020 - classifying contraceptives.

With the renewed focus on family planning, a clear and transparent understanding is needed for the consistent classification of contraceptives, especially in the commonly used modern/traditional system. The World Health Organization Department of Reproductive Health and Research and the United States Agency for International Development (USAID) therefore convened a technical consultation in January 2015 to address issues related to classifying contraceptives. The consultation defined modern contraceptive methods as having a sound basis in reproductive biology, a precise protocol for correct use and evidence of efficacy under various conditions based on appropriately designed studies. Methods in country programs like Fertility Awareness Based Methods [such as Standard Days Method (SDM) and TwoDay Method], Lactational Amenorrhea Method (LAM) and emergency contraception should be reported as modern. Herbs, charms and vaginal douching are not counted as contraceptive methods as they have no scientific basis in preventing pregnancy nor are in country programs. More research is needed on defining and measuring use of emergency contraceptive methods, to reflect their contribution to reducing unmet need. The ideal contraceptive classification system should be simple, easy to use, clear and consistent, with greater parsimony. Measurement challenges remain but should not be the driving force to determine what methods are counted or reported as modern or not. Family planning programs should consider multiple attributes of contraceptive methods (e.g., level of effectiveness, need for program support, duration of labeled use, hormonal or nonhormonal) to ensure they provide a variety of methods to meet the needs of women and men.

Scaling-up a public health innovation: a comparative study of post-abortion care in Bolivia and Mexico.

Post-abortion care (PAC), an innovation for treating women with complications of unsafe abortion, has been introduced in public health systems around the world since the 1994 International Conference on Population and Development (ICPD). This article analyzes the process of scaling-up two of the three key elements of the original PAC model: providing prompt clinical treatment to women with abortion complications and offering post-abortion contraceptive counseling and methods in Bolivia and Mexico. The conceptual framework developed from this comparative analysis includes the environmental context for PAC scale-up; the major influences on start-up, expansion, and institutionalization of PAC; and the health, financial, and social impacts of institutionalization. Start-up in both Bolivia and Mexico was facilitated by innovative leaders or catalyzers who were committed to introducing PAC services into public health care settings, collaboration between international organizations and public health institutions, and financial resources. Important processes for successful PAC expansion included strengthening political commitment to PAC services through research, advocacy, and partnerships; improving health system capacity through training, supervision, and development of service guidelines; and facilitating health system access to essential technologies. Institutionalization of PAC has been more successful in Bolivia than Mexico, as measured by a series of proposed indicators. The positive health and financial impacts of PAC institutionalization have been partially measured in Bolivia and Mexico. Other hypotheses--that scaling-up PAC will significantly reduce maternal mortality and morbidity, decrease abortion-related stigma, and prepare the way for efforts to reform restrictive abortion laws and policies--have yet to be tested.