Reproductive outcomes following contraceptive discontinuation for method-related reasons: An analysis of 49 Demographic and Health Surveys.

Contraceptive discontinuation for method-related reasons is a common experience in low- and middle-income countries (LMICs) and may heighten women's risk of unintended pregnancy. Few studies have provided a comprehensive assessment of reproductive outcomes following contraceptive discontinuation in LMICs over the last decade. Using cross-sectional data from 49 Demographic and Health Surveys, we applied competing risks estimation to calculate monthly probabilities of contraceptive resumption and pregnancy over a 12-month period among pooled, regional, and country-specific samples of women who discontinued contraception for method-related reasons (corresponding to 174,726 episodes of discontinuation). We also examined the pregnancy intention status of births/current pregnancies among those who became pregnant in the 12 months following contraceptive discontinuation for method-related reasons. In the pooled sample, the three-month probability of pregnancy and resumption of contraceptive use was 12% and 47%, respectively; by 12 months these probabilities increased to 22% and 55%, respectively. Country-specific analyses show that the probabilities of resuming contraception by three months ranged from 15% in Liberia, Mali, and Sierra Leone to 85% in Bangladesh. On average, the majority of pregnancies/births that occured following discontinuation for method-related reasons were subsequently reported as unintended. However, reports varied depending on when women became pregnant within the 12 months following discontinuation. Our findings suggest the need for more nuanced measures of contraceptive use dynamics-including measures that distinguish between women who resume use of contraception from women who remain at risk of pregnancy in the short period after discontinuation-to better inform specific policies and interventions, particularly aimed at those who remain at risk of pregnancy.

The Relationship Between Contraceptive Method Use and Return of Fecundity Among Women Attempting Pregnancy in Low- and Middle-Income Countries.

One of the most common barriers to using effective family planning methods is the belief that hormonal contraceptives and contraceptive devices have adverse effects on future fertility. Recent evidence from high-income settings suggests that some hormonal contraceptive methods are associated with delays in return of fecundity, yet it is unclear if these findings generalize to low- and middle-income populations, especially in regions where the injectable is widely used and pressure to bear children is significant. Using reproductive calendar data pooled across 47 Demographic and Health Surveys, we find that the unadjusted 12-month probability of pregnancy for women attempting pregnancy after discontinuing traditional methods, condoms, the pill, and the IUD ranged from 86% to 91%. The 12-month probability was lowest among those who discontinued injectables and implants, with approximately 1 out of 5 women not becoming pregnant within one year after discontinuation. Results from multivariable analysis showed that compared with users of either periodic abstinence or withdrawal, users of the pill, IUD, injectable, and implant had lower fecundability following discontinuation, with the largest reductions occurring among women who used injectables and implants. These findings indicate that women's concerns about potential short-term reductions in fecundity following contraceptive use are not unfounded.

Stop or Switch: Correlates of Stopping Use or Switching Contraceptive Methods While Wanting to Avoid Pregnancy in 48 Low- and Middle-Income Countries.

Contraceptive discontinuation for method-related reasons, while presumably wanting to avoid pregnancy, is a common phenomenon and can contribute to high levels of unmet need and unplanned pregnancies. Some women discontinue contraceptive use and do not quickly resume a method ("stopping"), while others are able to quickly switch to another method to achieve their reproductive goal of avoiding pregnancy ("switching"). We use Demographic and Health Survey data from 48 countries to examine what differentiates women who were able to switch to another method versus those who ultimately stopped entirely, among women who discontinued contraception for method-related reasons. Results show that wanting to limit births, having ever been married, and recent prior use are all associated with switching versus stopping. In addition, we find that women in West and Middle Africa were more likely to stop use compared to women in other regions. Addressing obstacles to contraceptive continuation, including effective method switching, among women who wish to delay or avoid pregnancy should be a priority for global and country initiatives aiming to deliver client-centered care that supports women and couples to make their best family planning choices.

The Know-Do Gap: Understanding and Improving Service Quality Among Pharmacies Providing Injectable Contraceptives Through a Mystery Client Study in Nepal.

Nepal is one of the first countries to license pharmacists to administer injectable contraceptives, through Nepal CRS Company's (CRS) Sangini private pharmacy network. There are more than 3,400 Sangini pharmacies in Nepal, including in hard-to-reach mountain areas, where these outlets are a key access point to injectables and other short-acting methods for those who lack access through the public sector or prefer the private sector.We compared the performance of Sangini pharmacists in (1) CRS-led technical support visits, when providers were aware of being observed, and (2) mystery client visits, when providers were not aware of being observed, to assess any gaps between pharmacists' knowledge and practices. We also assessed how well Sangini providers counseled on injectables and compared counseling on injectables with counseling for oral contraceptives.We found high levels of adherence to training guidelines on counseling on injectables. However, we identified significant differences between pharmacists' understanding of what they should do and what they actually do in practice, referred to as the know-do gap, in providing privacy, assessing client needs, and determining medical eligibility for hormonal methods. CRS took several steps to narrow the know-do gap through its programming, which may be a useful example for other countries as they expand the role of pharmacies in family planning service provision. Despite highlighting several areas for improvement, the findings show that Sangini providers both know how to and practice appropriate counseling on both injectable and oral contraceptives, suggesting that pharmacists can successfully expand their family planning offerings and equip clients with the information needed to select an appropriate method of their choice.

Where Women Access Contraception in 36 Low- and Middle-Income Countries and Why It Matters.

We examined where women access modern contraceptives, using recent Demographic and Health Survey data from 36 low- and middle-income countries and disaggregating results by contraceptive method, age, marital status, residence, socioeconomic status, and country income. We used bivariate and multivariate regression analysis to assess how demographic factors are associated with contraceptive source. In pooled analysis across countries analyzed, we found that 34% of users rely on private sources, 63% use public sources, and 3% use other sources. Among private sector users, 41% use pharmacies or drug shops, 11% general shops or markets, 36% private hospitals and clinics, and 12% nongovernmental or faith-based organizations. This analysis demonstrates the importance of the private sector for specific population segments including women in the wealthiest population quintile (odds ratio [OR]: 4.09, P<.001 compared with women in the poorest quintile), adolescents (OR: 2.03, P<.001 compared with women ages 40-49), never married women (OR 1.55, P<.001 compared with ever-married women), and urban women (OR: 1.42, P<.001 compared with rural women). The private sector does not only serve these populations, however. On average across countries analyzed, 22% of the poorest contraceptive users and 27% of rural users use private sources. Leveraging both sectors is key to meeting the reproductive needs of women across all sociodemographic groups in low- and middle-income countries.

Sources for and quality of neonatal care in 45 low- and middle-income countries.

Almost half of under-five deaths occur during the neonatal period. Delivery with a skilled attendant, adherence to essential newborn care (ENC) and postnatal care (PNC) standards, and immediate treatment of infections are essential to improve neonatal survival. This article uses Demographic and Health Survey data from 45 low- and middle-income countries to assess 1) levels of ENC and PNC that mothers and newborns receive and how this differs by place of delivery and 2) levels of and sources for care-seeking for neonates sick with fever. For five of the ten ENC and PNC indicators assessed, less than two-thirds of mothers and newborns received care in alignment with global standards. Adherence is higher in private facilities than public facilities for all indicators other than immediate breastfeeding and skin-to-skin contact. Except for immediate breastfeeding, adherence is lowest for newborns born at home with a skilled birth attendant (SBA). Socioeconomic disparities exist in access to skilled delivery and adherence to ENC and PNC, with the largest disparities among newborns delivered at home with a SBA. Private provider adherence to ENC and PNC standards was relatively high for newborns from the wealthiest families, indicating that meeting recommended guidelines is achievable. On average across the 45 countries, half of caregivers for neonates with fever sought care outside the home and 45 percent of those sought care from the private sector. There were substantial socioeconomic disparities in care-seeking for fever, but illness prevalence and sources of care seeking were consistent across wealth quintiles. Closing inequities in neonatal care and care seeking and ensuring that all families, including the poorest, can access high quality maternal and newborn care is crucial to ensure equity and accelerate reductions in neonatal and child mortality.

Measuring Service Quality and Assessing Its Relationship to Contraceptive Discontinuation: A Prospective Cohort Study in Pakistan and Uganda.

BACKGROUND: The quality of contraceptive counseling that women receive from their provider can influence their future contraceptive continuation. We examined (1) whether the quality of contraceptive service provision could be measured in a consistent way by using existing tools from 2 large-scale social franchises, and (2) whether facility quality measures based on these tools were consistently associated with contraceptive discontinuation. METHODS: We linked existing, routinely collected facility audit data from social franchise clinics in Pakistan and Uganda with client data. Clients were women aged 15-49 who initiated a modern, reversible contraceptive method from a sampled clinic. Consented participants completed an exit interview and were contacted 3, 6, and 12 months later. We collapsed indicators into quality domains using theory-based categorization, created summative quality domain scores, and used Cox proportional hazards models to estimate the relationship between these quality domains and discontinuation while in need of contraception. RESULTS: The 12-month all-modern method discontinuation rate was 12.5% among the 813 enrolled women in Pakistan and 5.1% among the 1,185 women in Uganda. We did not observe similar associations between facility-level quality measures and discontinuation across these 2 settings. In Pakistan, an increase in the structural privacy domain was associated with a 60% lower risk of discontinuation, adjusting for age and baseline method (P<.001). In Uganda, an increase in the management support domain was associated with a 33% reduction in discontinuation risk, controlling for age and baseline method (P=.005). CONCLUSIONS: We were not able to leverage existing, widely used quality measurement tools to create quality domains that were consistently associated with discontinuation in 2 study settings. Given the importance of contraceptive service quality and recent advances in indicator standardization in other areas, we recommend further effort to harmonize and simplify measurement tools to measure and improve contraceptive quality of care for all.

Where Do Caregivers Take Their Sick Children for Care? An Analysis of Care Seeking and Equity in 24 USAID Priority Countries.

Pneumonia, diarrhea, and malaria are leading causes of under-5 mortality. Accelerated reductions in illness burden are needed to meet childhood Sustainable Development Goals. Understand-ing where parents take sick children for care is key to improving equitable, high-quality treatment for these childhood illnesses and catalyzing reductions in morbidity and mortality. We analyzed the most recent Demographic and Health Survey data in 24 of the United States Agency for International Development's maternal and child health priority countries to examine levels and sources of care for children sick with 3 illness classifications: symptoms of acute respiratory infection, diarrhea, or fever. On average, across countries analyzed, one-third of children had recent experience with at least 1 of the 3 classifications. The majority (68.2%) of caregivers sought external advice or treatment for their sick children, though the level is far higher for the wealthiest (74.3%) than poorest (63.1%) families. Among those who sought out-of-home care, 51.1% used public sources and 42.5% used private-sector sources. Although sources for sick child care varied substantially by region and country, they were consistent across the 3 illness classifications. Urban and wealthier families reported more use of private sources compared with rural and poorer families. Though 35.2% of the poorest families used private sources, most of these (57.2%) were retail outlets like pharmacies and shops, while most wealthier families who sought care in the private sector went to health facilities (62.4%). Efforts to strengthen the quality of integrated management of sick child care must therefore reach both public and private facilities as well as private pharmacies, shops, and other retail outlets. Stakeholders across sectors must collaborate to reach all population groups with high-quality child health services and reduce disparities in care-seeking behaviors. Such cross-sectoral efforts will build clinical and institutional capacity and more efficiently allocate resources, ultimately resulting in stronger, more resilient health systems.

Do home pregnancy tests bring women to community health workers for antenatal care counselling? A randomized controlled trial in Madagascar.

Task-shifting the provision of pregnancy tests to community health workers (CHWs) in low-resource settings has the potential to reach significantly more underserved women at risk of pregnancy with essential reproductive health services. This study assessed whether an intervention to supply CHWs with home pregnancy tests brought more clients for antenatal care (ANC) counselling. We implemented a randomized controlled trial among CHWs providing reproductive health services to women in Eastern Madagascar. We used ordinary least squares regressions to estimate the effect of the intervention, with district- and month-fixed effects and CHW baseline characteristics as control variables. Our outcomes of interest included whether the intervention increased: (1) the number of women at risk of pregnancy who sought services from CHWs; (2) the number of these women who knew they were pregnant by the end of visit; and (3) the number of these women who received ANC counselling during visit. We found that providing pregnancy tests to CHWs to distribute to their clients for free significantly increased the number of women at risk of pregnancy who sought services from CHWs. At follow-up, treatment-group CHWs provided services to 6.3 clients compared with 4.2 clients among control-group CHWs, which represents a 50% relative increase from the control-group mean. A significantly higher number of these clients knew they were pregnant by the end of the visit, with a mean of 0.95 in treatment compared with 0.10 in control (Coeff. 0.86; 95% CI 0.59-1.13). A significantly higher number of these clients received antenatal counselling at the visit (Coeff. 0.4; 95% CI 0.14-0.64). Introducing free home pregnancy tests as part of community-based health services can improve pregnancy care by attracting more clients at risk of pregnancy to services at the community level, enabling more women to confirm they are pregnant and receive antenatal counselling.

Global Contraceptive Failure Rates: Who Is Most at Risk?

Contraceptive failure is a major contributor to unintended pregnancy worldwide. DHS retrospective calendars, which are the most widely used data source for estimating contraceptive failure in low-income countries, vary in quality across countries and surveys. We identified surveys with the most reliable calendar data and analyzed 105,322 episodes of contraceptive use from 15 DHSs conducted between 1992 and 2014. We estimate contraceptive method-specific 12-month failure rates. We also examined how failure rates vary by age, education, socioeconomic status, contraceptive intention, residence, and marital status using multilevel piecewise exponential hazard models. Our failure rate estimates are significantly lower than results from the United States and slightly higher than previous studies that included more DHS surveys, including some with lower-quality data. We estimate age-specific global contraceptive failure rates and find strong, consistent age patterns with the youngest users experiencing failure rates up to ten times higher than older women for certain methods. Failure also varies by socioeconomic status, with the poorest, and youngest, women at highest risk of experiencing unintended pregnancy due to failure.

Typical-use contraceptive failure rates in 43 countries with Demographic and Health Survey data: summary of a detailed report.

BACKGROUND: While most unintended pregnancies occur because couples do not use contraception, contraceptive failure is also an important underlying cause. However, few recent studies outside of the United States have estimated contraceptive failure rates, and most such studies have been restricted to married women, to a limited number of countries and to 12-month failure rate estimates. METHODS: Using self-reported data from 43 countries with Demographic and Health Survey data, we estimated typical-use contraceptive failure rates for seven contraceptive methods at 12, 24 and 36months of use. We provide a median estimate for each method across 43 countries overall, in seven subregions and in individual countries. We assess differences by various demographic and socioeconomic characteristics. Estimates are not corrected for potential errors in retrospective reporting contraceptive use or potential underreporting of abortion, which may vary by country and subgroups within countries. RESULTS: Across all included countries, reported 12-month typical-use failure rates were lowest for users of longer-acting methods such as implants (0.6 failures per 100 episodes of use), intrauterine devices (1.4) and injectables (1.7); intermediate for users of short-term resupply methods such as oral contraceptive pills (5.5) and male condoms (5.4); and highest for users of traditional methods such as withdrawal (13.4) or periodic abstinence (13.9), a group largely using calendar rhythm. CONCLUSIONS: Our findings help us to highlight those methods, subregions and population groups that may be in need of particular attention for improvements in policies and programs to address higher contraceptive failure rates.

Reassessing Unmet Need for Family Planning in the Postpartum Period.

Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times: right after delivery (prospective indicator), after six months of amenorrhea (intermediate indicator), and at the end of amenorrhea (classic indicator). DHS data from 57 countries in 2005-13 indicate that 62 percent (prospective), 43 percent (intermediate), and 32 percent (classic) of women in the first year after a birth have an unmet need for contraception (40 percent when including abstinence). While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods' widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.

Improving estimates of insecticide-treated mosquito net coverage from household surveys: using geographic coordinates to account for endemicity.

BACKGROUND: Coverage estimates of insecticide-treated nets (ITNs) are often calculated at the national level, but are intended to be a proxy for coverage among the population at risk of malaria. The analysis uses data for surveyed households, linking survey enumeration areas (clusters) with levels of malaria endemicity and adjusting coverage estimates based on the population at risk. This analysis proposes an approach that is not dependent on being able to identify malaria risk in a location during the survey design (since survey samples are typically selected on the basis of census sampling frames that do not include information on malaria zones), but rather being able to assign risk zones after a survey has already been completed. METHODS: The analysis uses data from 20 recent nationally representative Demographic and Health Survey (DHS), Malaria Indicator Surveys (MIS), an AIDS Indicator Survey (AIS), and an Anemia and Malaria Prevalence Survey (AMP). The malaria endemicity classification was assigned from the Malaria Atlas Project (MAP) 2010 interpolated data layers, using the Geographic Positioning System (GPS) location of the survey clusters. National ITN coverage estimates were compared with coverage estimates in intermediate/high endemicity zones (i.e., the population at risk of malaria) to determine whether the difference between estimates was statistically different from zero (p-value <0.5). RESULTS: Endemicity varies substantially in eight of the 20 studied countries. In these countries with heterogeneous transmission of malaria, stratification of households by endemicity zones shows that ITN coverage in intermediate/high endemicity zones is significantly higher than ITN coverage at the national level (Burundi, Kenya, Namibia, Rwanda, Tanzania, Senegal, Zambia, and Zimbabwe.). For example in Zimbabwe, the national ownership of ITNs is 28%, but ownership in the intermediate/high endemicity zone is 46%. CONCLUSION: Incorporating this study's basic and easily reproducible approach into estimates of ITN coverage is applicable and even preferable in countries with areas at no/low risk of malaria and will help ensure that the highest-quality data are available to inform programmatic decisions in countries affected by malaria. The extension of this type of analysis to other malaria interventions can provide further valuable information to support evidence-based decision-making.

Understanding unmet need: history, theory, and measurement.

During the past two decades, estimates of unmet need have become an influential measure for assessing population policies and programs. This article recounts the evolution of the concept of unmet need, describes how demographic survey data have been used to generate estimates of its prevalence, and tests the sensitivity of these estimates to various assumptions in the unmet need algorithm. The algorithm uses a complex set of assumptions to identify women: who are sexually active, who are infecund, whose most recent pregnancy was unwanted, who wish to postpone their next birth, and who are postpartum amenorrheic. The sensitivity tests suggest that defensible alternative criteria for identifying four out of five of these subgroups of women would increase the estimated prevalence of unmet need. The exception is identification of married women who are sexually active; more accurate measurement of this subgroup would reduce the estimated prevalence of unmet need in most settings.