Inequities in Family Planning in Low- and Middle-Income Countries.

INTRODUCTION: Inequities in reproductive health are widespread, and periodic surveys can trace trends in inequities to guide policies and program implementation. METHODS: We examined National Composite Index for Family Planning surveys from 2017 and 2021 that assessed inequities in access to 7 contraceptive methods and traced patterns of discrimination involving 5 subgroups in low- and middle-income countries. These surveys use 10-25 informants in each country who are knowledgeable at the national level. Measures are based on questionnaire ratings on a scale of 1-10. RESULTS: Access to contraceptive methods averages about half of the maximum of 100%, with substantial variation across regions and countries for the score levels. Score profiles are similar among high-scoring and low-scoring countries, suggesting that access to each method reflects common determinants in the nature of each method and the influences acting upon national family planning programs. Access to short-term methods (pill, injectable, and condom) is much better than for long-term methods (sterilization, intrauterine device, and implant). Community-based distribution of contraceptives averages low, as it is not part of some programs. Over time the scores have improved modestly. Correlations imply that better access leads to more contraceptive use. Inequity of use across wealth groups is less where overall equity has improved. Measures of discrimination against youth, unmarried women, postabortion clients, HIV carriers, and different wealth groups indicate a need for additional policies and considerable latitude for stronger actions by providers. CONCLUSIONS: The surveys in 2017 and 2021 demonstrate both progress and deficiencies for equitable access to contraceptive methods, with highly variable results among regions and countries. Much remains to be done to alleviate discriminatory practices against particular subgroups. Equity has improved for access to contraception and contraceptive use, and it can continue to do so with greater attention to policies and practices in national programs.

What interventions are effective to prevent or respond to female genital mutilation? A review of existing evidence from 2008-2020.

As the final decade of acceleration towards zero new cases of Female Genital Mutilation (FGM, SDG Target 5.3) by 2030 has begun, increasing the rigour, relevance, and utility of research for programming, policy development and resource allocation is critical. This study aimed to synthesize and assess the quality and strength of existing evidence on interventions designed to prevent or respond to FGM between 2008 and 2020.The study drew on a Rapid Evidence Assessment of the available literature on FGM interventions. The quality of studies was assessed using the 'How to Note: Assessing the Strength of Evidence' guidelines published by the Foreign, Commonwealth and Development Office (FCDO) and strength of evidence using a modified Gray scale developed by the What Works Association. Of the 7698 records retrieved, 115 studies met the inclusion criteria. Of the 115 studies, 106 were of high and moderate quality and were included in the final analysis. This review shows that at the system level, legislation-related interventions must be multifaceted to be effective. Whilst all levels would benefit from more research, for the service level especially more research is needed into how the health system can effectively prevent and respond to FGM. Community-level interventions are effective for changing attitudes towards FGM, but more must be done to innovate with these interventions so that they move beyond affecting attitudes alone to creating behaviour change. At the individual level, formal education is effective in reducing FGM prevalence among girls. However, the returns of formal education in ending FGM may take many years to be realized. Interventions targeting intermediate outcomes, such as improvement in knowledge and change in attitudes and beliefs towards FGM, are equally needed at the individual level.

The National Composite Index for Family Planning (NCIFP): Results and Methodological Issues.

Background:  The " FP2020 Global Partnership" signaled a shift to broader, rights-based approaches to family planning programs, and the National Composite Index for Family Planning was developed as part of related measurement efforts. Methods: In each country 10-15 experts on the family planning program completed a 35-item questionnaire, first in 2014 in 89 countries, and in 2017 in 84 countries. Data were entered in Excel, with checks for consistency and data quality. The total score, and scores for each of 5 dimensions of effort are averages across the 35 indicators. Analytic techniques included cross-tabulations, graphical and correlation approaches. Results: The average total score for all countries in 2017 was 64 of the maximum of 100 of effort. Sub-regions differed: Anglophone and Francophone sub-Saharan Africa (SSA) scored highest in the total score and across all 5 dimensions. Next in order came Latin America and the Caribbean, Asia, the Middle East and North Africa, and Eastern Europe and Central Asia. Despite large differences in scores, the sub-regions followed similar profiles across the 35  indicators. The long term rise in the basic family planning effort scores continued, extending the series from surveys approximately every five years beginning in the 1980s. The highest score reached was for the strategy dimension, but the others were close. Their relative levels remained essentially the same as in the 2014 survey.                     NCIFP scores correlated positively with modern contraceptive use in both the sub-Saharan Africa (SSA) and non-sub-Saharan Africa (non-SSA) countries, but the relationships were stronger for SSA. Access to long-acting and permanent methods (LAPMs) was accompanied by greater LAPM use and modern method use. Conclusion: Repeated surveys in most developing countries show improvements in family planning effort, though unevenly, by 35 indicators and across regions.

A long way to go: engagement of men and boys in country family planning commitments and implementation plans.

Background: To reach global goals related to women and girls' access to modern family planning (FP) and gender equality, evidence shows that it is critical to understand and account for the role of men and boys as users of reproductive health services, as partners for millions of women & girls around the world, and as advocates in their communities. Under the Family Planning 2020 (FP2020) partnership, countries were encouraged to develop costed implementation plans and action plans in an effort to provide 120 million additional women and girls with contraception. As FP2020 becomes FP2030, reviewing these previously-developed strategies helps understand the extent to which countries considered the engagement of men as an important aspect of their family planning portfolios. Methods: We conducted textual analysis on commitments and implementation plans related to achieving FP2020 commitments in six countries in Africa and one in Asia to determine the extent to which male engagement was incorporated into country or subnational family planning goals, with particular focus on FP policy, program, and financial commitments.  Results: Some of the documents analyzed included robust plans for including male engagement in their efforts to expand access to FP.  The strongest aspects of male engagement programming were those that sought to engage men as advocates for women's access to and use of FP services, and improve their knowledge and attitudes related to contraception and reproduction. The weakest aspects were engaging men as users of services and, vitally, tackling underlying gender norms which hamper men's and women's health-seeking behaviors and attitudes. Conclusions: Developing FP programs that target men and boys as people deserving of reproductive health services, as partners with women in building their families, and as social activists in their communities, will complement and strengthen existing FP programs as well as promote broader goals related to gender equality.

Advancing Rights-Based Family Planning from 2020 to 2030.

INTRODUCTION: An assessment in 2019 by Family Planning 2020 of progress on rights-based family planning since 2012 highlighted the development of tools and guidelines that identify and explain rights in relation to family planning, promotion of rights-based approaches to programing, strengthened accountability, and measurement of rights-focused outcomes. The assessment was also forward-looking, asking what aspects of rights-based family planning still need attention moving from 2020 to 2030. METHODS: This paper draws on interviews with 23 key informants from governments, civil society, and youth focused organizations, implementing partners, and bi-lateral and multilateral organizations from Africa, Asia and the Pacific, Europe and North America, all working on family planning and engaged in various roles with the FP2020 partnership at global and national levels, along with documentation of FP2030 partnership plans. The interviews were conducted as part of the assessment and included questions to respondents for their recommendations on rights-based family planning moving towards 2030. RESULTS: Respondents agreed that rights should be at the center of the vision for family planning, with attention to rights literacy, accountability and equity, including adolescent and youth leadership. They noted the need for consistent political and financial support, and incorporating rights into result-based financing programming. While respondents noted the need for development and dissemination of practical tools and training materials, along with rights metrics and implementation research, they stressed the importance of focusing work on rights at the country level. Respondents also acknowledged that institutionalizing rights-based family planning will require enhanced commitment and funding from both donors and countries to ensure programming - and success - over the long term. Amplifying civil society and particularly adolescent and youth voices will be key to engaging governments to support both rights-based programming and provide funding. Review of initial planning under FP2030 related to each of the recommendations suggests that the new partnership is seeking to addressing each of them. DISCUSSION: As the family planning field looks beyond 2020 to 2030, this paper provides a roadmap for building on the gains made over the past decade to effectively tackle the challenges remaining to ensure that programming to achieve the vision of the FP2030 Partnership is rights-based.

Contraceptive Method Mix: Updates and Implications.

CONTEXT: Improving contraceptive method choice is a goal of international family planning. Method mix-the percentage distribution of total contraceptive use across various methods-reflects both supply (availability of affordable methods) and demand (client preferences). We analyze changes in method mix, regional contrasts, and the relationship of the mix to contraceptive prevalence. METHODS: We use 789 national surveys from the 1960s through 2019, from 113 developing countries with at least 1 million people and with data on use of 8 contraceptive methods. Two measures assess the "evenness" of the mix: method skew (more than 50% use is by 1 method), and the average deviation (AD) of the 8 methods' shares from their mean value. Population weighted and unweighted results are compared because they can differ substantially. RESULTS: Use of traditional methods has declined but still represents 11% of all use (population weighted) or 17% (unweighted country average). Vasectomy's share was historically low with the exception of a few countries but is now even lower. The previous trend toward greater overall evenness in the mix has slowed recently. Sub-Saharan Africa shows a hormonal method progression from oral contraceptives to injectables to implants in a substantial number of countries. In some countries with high HIV prevalence, the condom share has increased. The leading method's share differs by region: female sterilization in Asia (39%) and in Latin America (31%), the pill in the Middle East/North Africa (32%), and the injectable in sub-Saharan Africa (36%). Method skew persists in 30% of countries. "Evenness" of mix is not related to contraceptive prevalence. CONCLUSION: The marked diversity in predominant methods underscores the conclusion that no single method mix is ideal or appropriate everywhere. But that diversity across countries, coupled with the persisting high degree of extreme skewness in many of them, argues for continued concerted efforts for programs to increase method choice.

Implementing social accountability for contraceptive services: lessons from Uganda.

BACKGROUND: Growing evidence shows that social accountability contributes to improving health care services, with much promise for addressing women's barriers in contraceptive care. Yet little is known about how social accountability works in the often-complex context of sexual and reproductive health, particularly as sex and reproduction can be sensitive topics in the open and public formats typical of social accountability. This paper explores how social accountability operates in the highly gendered and complex context of contraceptive care. METHODS: This exploratory research uses a case study approach to provide a more grounded understanding of how social accountability processes operate in the context of contraceptive information and services. We observed two social accountability projects that predominantly focused on contraceptive care in Uganda over a year. Five instruments were used to capture information from different source materials and multiple respondents. In total, one hundred and twenty-eight interviews were conducted and over 1000 pages of project documents were collected. Data were analyzed and compiled into four case studies that provide a thick description of how these two projects operated. RESULTS: The case studies show the critical role of information, dialogue and negotiation in social accountability in the context of contraceptive care. Improved community and health system relationships, community empowerment, provider and health system responsiveness and enhanced availability and access to services were reported in both projects. There were also changes in how different actors related to themselves and to each other, and contraceptive care, a previously taboo topic, became a legitimate area for public dialogue. CONCLUSION: The study found that while social accountability in the context of contraceptive services is indeed sensitive, it can be a powerful tool to dissolving resistance to family planning and facilitating a more productive discourse on the topic.

Improving Voluntary, Rights-Based Family Planning: Experience From Nigeria And Uganda.

BACKGROUND: Growing focus on the need for voluntary, rights-based family planning (VRBFP) has drawn attention to the lack of programs that adhere to the range of rights principles. This paper describes two first-of-their-kind interventions in Kaduna State, Nigeria and in Uganda in 2016-2017, accompanied by implementation research based on a conceptual framework that translates internationally agreed rights into family planning programming. METHODS: This paper describes the interventions, and profiles lessons learned about VRBFP implementation from both countries, as well as measured outcomes of VRBFP programming from Nigeria. RESULTS: The intervention components in both projects were similar. Both programs built provider and supervisor capacity in VRBFP using comparable curricula; developed facility-level action plans and supported action plan implementation; aimed to increase clients' rights literacy at the facility using posters and handouts; and established or strengthened health committee structures to support VRBFP. Through the interventions, rights literacy increased, and providers were able to see the benefits of taking a VRBFP approach to serving clients. The importance of ensuring a client focus and supporting clients to make their own family planning choices was reinforced. Providers recognized the importance of treating all clients, regardless of age or marital status, for example, with dignity. Privacy and confidentiality were enhanced. Recognition of what violations of rights are and the need to report and address them through strong accountability systems grew. Many lessons were shared across the two countries, including the need for rights literacy; attention to health systems issues; strong and supportive supervision; and the importance of working at multiple levels. Additionally, some unique lessons emanated from each country experience. CONCLUSION: The assessed feasibility and benefits of using VRBFP programming and outcome measures in both countries bode well for adoption of this approach in other geographies.

Trends in Contraceptive Prevalence in Sub-Saharan Africa: The Roles of Family Planning Programs and Education.

Since the 1990s some countries in Africa have experienced very rapid increases in contraceptive prevalence (e.g. Ethiopia, Malawi, Rwanda), while others (e.g. Nigeria) have seen little change. This study aims to shed light on the causes of these different trends which remain controversial. We assess the role of family planning programs vs. socioeconomic development (especially, women's educational attainment). Estimates of the effects of different explanatory factors are obtained by country level regressions in which the prevalence of modern contraception is the dependent variable and women's educational attainment, Gross National Income (GNI) per capita, percent urban and child mortality as well as the family planning program score are the independent variables. The statistical analysis finds no significant effects of GNI per capita, percent urban and child mortality. In contrast, women's educational attainment and program score have highly significant effects and are the dominant drivers of contraceptive prevalence trends. Voluntary family planning programs can increase contraceptive prevalence at all levels of female education. The best programs with prevalence impact above 30% (relative to no program effort) are found in Zimbabwe, Malawi, Kenya, Rwanda, Zambia and Ethiopia. Without family planning programs prevalence remains low even where education levels have risen substantially.

The Extent to Which Performance-Based Financing Programs' Operations Manuals Reflect Rights-Based Principles: Implications for Family Planning Services.

Recognition is growing that development programs need to be guided by rights as well as to promote, protect, and fulfill them. Drawing from a content analysis of performance-based financing (PBF) implementation manuals, we quantify the extent to which these manuals use a rights perspective to frame family planning services. PBF is an adaptable service purchasing strategy that aims to improve equity and quality of health service provision. PBF can contribute toward achieving global family planning goals and has institutional support from multiple development partners including the Global Financing Facility in support of Every Woman Every Child. A review of 23 PBF implementation manuals finds that all documents are focused largely on the implementation of quality and accountability mechanisms, but few address issues of accessibility, availability, informed choice, acceptability, and/or nondiscrimination and equity. Notably, operational inclusion of agency, autonomy, empowerment, and/or voluntarism of health care clients is absent. Based on these findings, we argue that current PBF programs incorporate some mention of rights but are not systematically aligned with a rights-based approach. If PBF programs better reflected the importance of client-centered, rights-based programming, program performance could be improved and risk of infringing rights could be reduced. Given the mixed evidence for PBF benefits and the risk of perverse incentives in earlier PBF programs that were not aligned with rights-based approaches, we argue that greater attention to the rights principles of acceptability, accessibility, availability, and quality; accountability; agency and empowerment; equity and nondiscrimination; informed choice and decision making; participation; and privacy and confidentiality would improve health service delivery and health system performance for all stakeholders with clients at the center. Based on this review, we recommend making the rights-based approach explicit in PBF; progressively operationalizing rights, drawing from local experience; validating rights-based metrics to address measurement gaps; and recognizing the economic value of aligning PBF with rights principles. Such recommendations anchor an aspirational rights agenda with a practical PBF strategy on the need and opportunity for validated metrics.

Trends in contraceptive prevalence in Sub-Saharan Africa: the roles of family planning programs and education

Since the 1990s some countries in Africa have experienced very rapid increases in contraceptive prevalence (e.g. Ethiopia, Malawi, Rwanda), while others (e.g. Nigeria) have seen little change. This study aims to shed light on the causes of these different trends which remain controversial. We assess the role of family planning programs vs. socioeconomic development (especially, women's educational attainment). Estimates of the effects of different explanatory factors are obtained by country level regressions in which the prevalence of modern contraception is the dependent variable and women's educational attainment,Gross National Income (GNI) per capita, percent urban and child mortality as well as the family planning program score are the independent variables. The statistical analysis finds no significant effects of GNI per capita, percent urban and child mortality. In contrast, women's educational attainment and program score have highly significant effects and are the dominant drivers of contraceptive prevalence trends. Voluntary family planning programs can increase contraceptive prevalence at all levels of female education. The best programs with prevalence impact above 30% (relative to no program effort) are found in Zimbabwe, Malawi, Kenya, Rwanda, Zambia and Ethiopia. Without family planning programs prevalence remains low even where education levels have risen substantially

Closing the Gap between People and Programs: Lessons from Implementation of Social Accountability for Family Planning and Reproductive Health in Uganda.

Globally, women's access to modern contraception can be attributed to poor service conditions and care. Growing evidence from across the health sector has found that social accountability approaches have the potential to improve the quality of care and therefore the utilization of health services, little of this evidence relates to family planning and reproductive health programs. This paper therefore assessed the results of retrospective implementation research into a five-year social accountability project in Uganda that focused on family planning and reproductive health. A mix of methods was used examine the project's implementation in three districts in Uganda between 2009 to 2013, including political economy analysis, document review, and in-depth interviews. Interviews were coded using ATLAS.ti software and analyzed with a thematic framework, organized by stakeholder groups and across districts. The research found that while the project broadly delivered as intended in local accounts, a wider range of activities and outcomes also occurred. Community participants in the three districts were much more likely to remember more personal changes, such as increased confidence when interacting with health care providers, in their health seeking behavior or in their ability to represent themselves. The research revealed a web of accountability relationships at play. These ranged from formal opportunities for community participation in institutional processes, to the more personal direct relationship between the service users and the health care provider compared to the less direct relationship between the community and local officials. In addition, ways in which elements of social accountability can be combined with features of FP program were seen, such as including outreach activities with civic and rights education. This appears to extend the reach and credibility of these services among community members while also counteracting barriers to women's and young people's participation.

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.

Family planning and resilience: associations found in a Population, Health, and Environment (PHE) project in Western Tanzania.

Using 2016 household survey data from Tanzania, we define and measure resilience within the context of Population, Health, and Environment programming and quantify the link between resilience and family planning. We created a multicomponent model using confirmatory factor analysis in a structural equation modeling context. Factor loadings for eight defined latent factors of resilience were statistically significant (p < 0.001). We created a factor called "FP-MCH" reflecting awareness, attitudes, and access to family planning (FP) and health care services and use of maternal and child health care (MCH) facilities. Analysis, with controls, shows that a 1 standard deviation (SD) increase in FP/MCH was associated with a 0.68 SD increase in resilience (p < 0.01), suggesting that the association between FP/MCH and resilience is robust across a range of factors. Analyses showed that the association between FP/MCH is broadly related to the construct of resilience and not through any single component. This study supports the importance of including FP/MCH as part of integrated projects to enhance resilience.

The Role of Public-Sector Family Planning Programs in Meeting the Demand for Contraception in Sub-Saharan Africa.

CONTEXT: Commonly used indicators of contraceptive behavior in a population-modern contraceptive prevalence (mCPR), unmet need for contraception, demand for contraception and demand satisfied-are not well-suited for evaluating the progress made by government family planning programs in helping women and men achieve their reproductive goals. METHODS: Trends in these measures in 26 Sub-Saharan African countries between 1990 and 2014 were examined. Trends in a proposed new indicator, the public-sector family planning program impact score (PFPI), and its relationship to mCPR and the family planning effort score were also assessed. Case studies were used to review public family planning program development and implementation in four countries (Nigeria, Ethiopia, Rwanda and Kenya). RESULTS: The four commonly used indicators capture the extent to which women use family planning and to which demand is satisfied, but shed no direct light on the role of family planning programs. PFPI provides evidence that can be used to hold governments accountable for meeting the demand for family planning, and was closely related to policy developments in the four case-study countries. CONCLUSIONS: PFPI provides a useful addition to the indicators currently used to assess progress in reproductive health and family planning programs.