Contraceptive dynamics among women with disabilities in low- and middle-income countries: a scoping review protocol.

INTRODUCTION: Contraceptive dynamics is the use of contraception, unmet need, discontinuation, and/or switching of contraception. Women with disabilities (WWDs) in low- and middle-income countries (LMICs) face a common problem: a low prevalence of contraceptive usage and a high unmet need. Even though certain studies have been conducted in high-income countries, research is scarce on the degree of contraceptive method mix, unmet needs, contraception discontinuation, and switching among WWDs in LMICs. As a result, the scoping review's goal is to investigate, map available evidence, and identify knowledge gaps on contraceptive dynamics within LMICs WWDs. METHODS: The scoping review is guided by the six-stage Arksey and O'Malley methodology framework. Published articles will be retrieved from databases such as PubMed (MEDLINE), the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Global Health. Grey literature databases will be searched using electronic search engines such as Google Scholar, Google, OpenGrey, and Worldcat. In addition, a manual search of reference lists from recognized studies will be conducted, as well as a hand search of the literature. Any type of study design (e.g., randomized controlled trials, quasi-experimental studies, prospective and retrospective cohort studies, case-control or nested case-control studies, qualitative, cross-sectional studies) will be included in this scoping review. There will be no restrictions on publication year. Two independent reviewers will screen relevant publications, and data will be charted accordingly. The Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist and reporting guidelines will be used to report all parts of the protocol and scoping review. DISCUSSION: When compared to non-disabled women, WWDs had a lower prevalence of contraceptive usage and a higher unmet need in LMICs. Despite these facts, they are the most marginalized people on the planet. This is, therefore, critical to map available evidence and identify knowledge gaps on contraceptive dynamics. As a result, the findings of this scoping review will be significant in terms of the contraceptive dynamic among WWDs in LMICs. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (OSF), with registration number; DOI/10.17605/OSF.IO/XCKPT.

How has contraceptive provision at Family Planning clinics in Aotearoa New Zealand changed between 2009, 2014 and 2019: a cross-sectional analysis.

AIM: To investigate changes in contraceptive starts among Family Planning clients in 2009, 2014 and 2019. METHODS: National data of 75,825 contraceptive starts of clients at Family Planning clinics in New Zealand in 2009, 2014 and 2019 were analysed to measure changes in contraceptive starts across the three points in time. Data were analysed by age and ethnicity at each point in time, and by deprivation in 2019. RESULTS: After being adjusted for age and ethnicity, there was a significant decline in the proportion of starts for the combined oral contraceptive pill (43% to 23%), the progestogen-only pill (22% to 13%) and Depo Provera (15% to 12%) from 2009 to 2019. There was a significant increase in the proportion of starts for implants (0.7% to 22%) and intra-uterine contraception (19% to 30%). There were significant differences in contraceptive starts between ethnicities and levels of deprivation. CONCLUSIONS: There was an overarching trend of increasing long-acting reversible contraceptive (LARC) starts from 2009 to 2019 among Family Planning clients across all age groups and ethnicities. There were also differences in the types of contraceptive starts by ethnicity and deprivation. Information about contraceptive use and changes over time, by age and ethnicity, is essential for evidence-based policy, funding decisions and ensuring equitable access to contraception.

Cash Transfers and Contraceptive Use: A Regression Discontinuity Analysis.

Conditional cash transfers (CCTs) have become important components of social protection policies in Latin America. By establishing coresponsibilities tied to health and education, CCTs may reduce poverty and encourage human capital investment. While CCT programs can have unintended effects on sexual and reproductive health outcomes, such effects have been mixed and poorly documented in South America. This study examines the impact of Ecuador's CCT program, Bono de Desarrollo Humano, on contraceptive behavior among women of childbearing age who are sexually active and do not wish to become pregnant. We analyze nationally representative data in a regression-discontinuity quasi-experimental design. Using an instrumental variable approach and a set of robustness checks, our study finds no significant effects of the CCT program on contraceptive use. Our results offer important considerations for the ongoing policy debate in South America regarding the effects of cash transfer programs on beneficiaries.

Out-of-pocket spending for contraceptives in Latin America.

Despite progress in increasing the use of modern contraceptives in most Latin American countries over the last few decades, important challenges remain, including the heavy reliance on out-of-pocket spending to access contraceptives, which may expose consumption to macroeconomic fluctuations. Out-of-pocket spending on contraceptives and/or the proportion of women aged 15-49 who received free contraceptives at a public health facility or as part of statutory health insurance were estimated for 13 Latin American countries using the most recently available household budget surveys and demographic and health or similar household surveys. Data on contraceptive retail sales in 12 countries over the 2006-2010 period and publicly available macroeconomic indicators were used to examine the relationship between changes in sales and macroeconomic indicators using multiple regression models. On average, women aged 15-49 spent close to US$1 per month out-of-pocket on contraceptives. However, almost three out of five women received them free of charge. A 1% increase in the percentage of the population living on less than US$ 3.2/day (2011 PPP values), or the percentage unemployed in the labour force, predicted about a 2% decrease in the growth of contraceptive retail sales (measured in couple-years of protection, CYP, per capita) the subsequent year. The analysis revealed the sensitivity of contraceptive retail sales to changes in macroeconomic variables, particularly changes in poverty levels. Achieving universal access to family planning by 2030 will require improving contraceptive financing schemes.

[Contraceptive use by married women or concubines living in rural areas in Burkina Faso: a qualitative study of free voucher use]. / Utilisation des contraceptifs par les femmes rurales mariées ou en concubinage au Burkina Faso: une analyse qualitative de l'utilisation d'un bon gratuit.

INTRODUCTION: low levels of contraceptive use in Western Africa are responsible for high fertility rates, which limits economic development. The cost of modern contraceptives is a significant constraint, then the government of Burkina Faso has implemented free family planning. Given this new policy, we provided rural women with a healthcare voucher giving free access to modern contraceptives. We conducted an analysis of the determinants of good free voucher use in order to implement adequate government policy. METHODS: six months after the distribution of vouchers to women living in 30 villages in the Houet Province, we conducted a focus-group study based on individual in-depth health care provider interviews in partner healthcare centers. RESULTS: the benefits of family planning, free contraceptive use, husband's approval and moral obligation were factors facilitating voucher use. The desire to become pregnant, husband's opposition, women's reluctance, women's lack of knowledge of contraceptives and factors associated with the intervention were the leading reasons for not using the vouchers. CONCLUSION: the promotion of modern contraceptive use among married women or concubines requires a holistic approach combining free access to modern contraceptives, effective policies involving men in family planning and the reduction of fertility preferences among the couples.

Contraceptive Mandate, ACA Final Rules, And COVID-19.

The Supreme Court upheld broad exemptions to the Affordable Care Act contraceptive mandate; new ACA rules were finalized.

Modeling the Impacts of Price of an Over-the-Counter Progestin-Only Pill on Use and Unintended Pregnancy among U.S. Women.

OBJECTIVE: To model the impacts of out-of-pocket cost of an over-the-counter (OTC) progestin-only pill on use and associated unintended pregnancy among U.S. women. STUDY DESIGN: Using data from a 2015 nationally representative survey of 2,539 U.S. women aged 15 to 44 assessing interest in using an OTC progestin-only pill, we used discrete survival analysis and a Markov model to analyze women's likelihood of using of an OTC pill at different price points and by sociodemographic characteristics. We modeled the impact of product price on the potential total number of U.S. users and on unintended pregnancies in 1 year among adult women at risk of unintended pregnancy. RESULTS: In a model assuming no out-of-pocket costs, more than 12.5 million adults and 1.75 million teens reported likely use of an OTC progestin-only pill if available. Among adults, this resulted in an estimated 8% decrease in unintended pregnancy in 1 year. Adult and teen women on average were willing to pay $15 and $10, respectively, resulting in 7.1 million adult and 1.3 million teen users and an estimated 5% decrease in unintended pregnancy among adults. CONCLUSIONS: At low and no out-of-pocket cost, a large population of women in the United States might likely use an OTC progestin-only pill. A low retail price and insurance coverage are necessary to provide equitable access to this method for low-income populations across the United States, fill current gaps in contraceptive access, and potentially decrease unintended pregnancy.

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.

Barriers to contraceptive careseeking: the experience of Eritrean asylum-seeking women in Israel.

Objectives: In recent years, there has been a mass migration of Eritreans (many seeking political asylum) into Israel after precarious irregular movement across international borders. This study qualitatively explores the structural barriers to family planning (i.e. contraceptive services) for Eritrean women in Israel that are rooted in their temporary legal status and the patchwork of family planning services.Design/Methods: From December 2012 to September 2013, we interviewed 25 key informants (NGO workers, researchers, Eritrean community activists, International NGO representatives and Ministry of Health officials) and 12 Eritrean asylum seekers. We also conducted 8 focus groups with Eritrean asylum seekers. Data were analyzed using both inductive and deductive coding.Results: We identified 7 main barriers to accessing family planning services: (1) distance to health facilities; (2) limited healthcare resources; (3) fragmentation of the healthcare system; (4) cost of contraceptive services; (5) low standard of care in private clinics; (6) discrimination; and (7) language barriers.Conclusion: The political, economic and social marginalization of Eritrean asylum-seeking women in Israel creates structural barriers to family planning services. Their marginalization complicates providers' efforts (NGO and governmental) to provide them with comprehensive healthcare, and hinders their ability to control their sexual and reproductive health. Failure to act on this evidence may perpetuate the pattern of unwanted pregnancies and social and economic disparities in this population.

Projecting the fiscal impact of South Africa's contraceptive needs: Scaling up family planning post 2020.

BACKGROUND: Evidence-informed priority setting is vital to improved investment in public health interventions. This is particularly important as South Africa (SA) makes the shift to universal health coverage and institution of National Health Insurance. OBJECTIVES: To measure the financial impact of increasing the demand for modern contraceptive methods in the SA public health sector. We estimated the total cost of providing contraceptives, and specifically the budgetary impact of premature removals of long-acting reversible contraceptives. METHODS: We created a deterministic model in Microsoft Excel to estimate the costs of contraception provision over a 5-year time horizon (2018 - 2023) from a healthcare provider perspective. Only direct costs of service provision were considered, including drugs, supplies and personnel time. Costs were not discounted owing to the short time horizon. Scenario analyses were conducted to test uncertainty. RESULTS: The base-case cost of current contraceptive use in 2018 was estimated to be ZAR1.64 billion (ZAR29 per capita). Injectable contraceptives accounted for ~47% of total costs. To meet the total demand for family planning, SA would have to spend ~30% more than the estimate for current contraceptive use. In the year 2023, the 'current use' of modern contraceptives would increase to ZAR2.2 billion, and fulfilling the total demand for family planning would require ZAR2.9 billion. The base-case cost of implantable contraceptives was estimated at ZAR54 million. Assuming a normal removal rate, the use of implants is projected to increase by 20% during the 5-year period between 2019 and 2023, with an estimated 46% increase in costs. The cost of early removal of Implanon NXT is estimated at ZAR75 million, with total contraception costs estimated at ZAR102 million in 2019, compared with ZAR56 million when a normal removal rate is applied. CONCLUSIONS: The costs of scaling up modern contraceptives in SA are substantial. Early and premature removals of implantable contraceptives are costly to the nation and must be minimised. The government should consider conducting appropriate health technology assessments to inform the introduction of new public health interventions as SA makes the shift to universal health coverage by means of National Health Insurance.

Youth Perspectives on Pharmacists' Provision of Birth Control: Findings From a Focus Group Study.

PURPOSE: Young women face numerous obstacles to accessing contraception, including lack of money, time, or transportation to visit a doctor. In addition, concerns about confidentiality deter many adolescents from seeking contraceptive care. Pharmacists in Washington, D.C. will soon be able to prescribe hormonal birth control, which can potentially increase contraceptive access for adolescents. This study explores the needs and concerns of teens and young women residing in Washington, D.C. to inform implementation of this service. METHODS: In this community-based participatory research study, four focus group discussions were conducted in February 2017, two with teen females aged 14-17 years and two with young women aged 18-24 years. A youth advisory council, comprising 13 women aged 16-22 years living in Washington, D.C., helped develop the discussion guide and interpret findings. Data were analyzed thematically by age group using inductive and deductive codes. RESULTS: Young people viewed pharmacies as convenient locations to access contraceptives but expressed concerns about privacy, affordability, and pharmacist approachability. Younger participants viewed these concerns as significant barriers for their peers. Participants suggested pharmacies protect privacy and confidentiality by offering private consultation spaces and clear information about what insurance plans can disclose to parents. Participants also recommended pharmacies create a youth-friendly, nonjudgmental environment and offer pharmacists training on contraceptive counseling for young women. CONCLUSIONS: Addressing concerns about privacy, costs, and pharmacist approachability can help ensure that youth seeking contraceptives can easily access their preferred method. Pharmacies should continuously incorporate young people's feedback to ensure this service remains accessible and acceptable to adolescents.

Factors Associated with New Uptake of Long-Acting Reversible Contraceptives Since the Affordable Care Act Among Privately Insured Women in Pennsylvania.

BACKGROUND: The Affordable Care Act eliminated out-of-pocket costs for contraceptives, including highly effective long-acting reversible contraception (LARC), for most insured women. Patient characteristics associated with new LARC uptake after the Affordable Care Act have not been well-studied. We hypothesized that awareness of no-cost intrauterine device (IUD) coverage would be associated with new LARC use. METHODS: Data included were from 883 women not using a LARC at baseline who participated in the MyNewOptions study, a 2-year study of privately insured women in Pennsylvania. Multivariable analysis assessed whether the following baseline characteristics predicted new LARC use over 2 years: awareness of no-cost IUD coverage, future pregnancy intention, baseline contraceptive use, contraceptive attitudes, and sociodemographic characteristics. RESULTS: At baseline, 54.4% of participants were using prescription methods; 21.1% nonprescription methods; 12.1% natural family planning, withdrawal, or spermicide alone; and 12.5% no method. A minority (7.2%) was aware of no-cost coverage for IUDs. Over 2 years, 7.2% of participants became new LARC users, but awareness of no-cost coverage for IUDs was not associated with new LARC use (adjusted odds ratio, 0.84; 95% confidence interval, 0.27-2.55). New LARC use was associated with already using prescription methods, not intending pregnancy within the next 5 years, prior unintended pregnancy, and desire to change method if cost were not a factor. CONCLUSIONS: Among privately insured women, wanting to switch methods if cost were not a factor was associated with new LARC uptake, although awareness of no-cost IUD coverage was not. Providing women with information about their contraceptive coverage benefits may help women to seek and obtain the methods better aligned with their personal needs.

Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya.

OBJECTIVES: Out-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants-two popular methods-differs by public/private provider type and user's sociodemographic characteristics. DESIGN, SETTING AND PARTICIPANTS: Secondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15-49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values. MAIN OUTCOME: Respondent's self-reported source and payment to obtain their current modern contraceptive method. METHODS: We used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth. RESULTS: Half of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users. CONCLUSIONS: More attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.

Prescription Contraceptive Sales Following the Affordable Care Act.

Objectives We examine trends in prescription contraceptive sales following the Affordable Care Act's (ACA) zero-copayment contraceptive coverage mandate in areas more likely to be affected by the provision relative to areas less likely to be affected. Methods Before the ACA, several states had their own contraceptive insurance coverage mandates. Using a national prescription claims database combined with wholesaler institutional sales activity from January 2008 through June 2014, we compare sales of the intrauterine device (IUD), implant, injectable, pill, ring, and patch in states that had a state-level insurance coverage mandate before the ACA to states that did not. Results Overall, our results imply the ACA increased sales of prescription contraceptives, with stronger effects for some methods than others. Specifically, we find the ACA increased sales of injectable contraceptives, but had no significant impact on sales of the IUD, implant, pill, or patch in states without a state-level mandate before the ACA relative to states that had a state-level mandate. We also find suggestive evidence of a reduction in sales of the ring. Conclusions for Practice Demand responses to changes in out-of-pocket expenses for contraception vary across methods. Eliminating copays could promote the use of contraceptives, but is not the only approach to increasing contraceptive utilization.

Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X-Funded Facilities in 2016.

CONTEXT: As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X-funded facilities under ACA guidelines is essential to understanding what is at stake. METHODS: A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X-funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi-square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types. RESULTS: Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign-born clients were less likely than U.S.-born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one-quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out. CONCLUSION: Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.

The Relationship Between Prescription Copayments and Contraceptive Adherence in a New-user Cohort.

BACKGROUND: Contraceptive nonadherence is an important contributor to unintended pregnancy in the United States. While the elimination of patient cost sharing has been cited as means to improve contraceptive access, little is known about the relationship between cost sharing and ongoing adherence and continuation of chosen methods. The purpose of this study was to examine the relationship between copayment amount and adherence to pharmacy-dispensed contraception in young women. METHODS: We conducted a retrospective cohort study of 39,142 women ages 19-29 with a new prescription for the contraceptive pill, patch, or ring at Kaiser Permanente Northern California during 2011-2014. We examined 12-month nonadherence as measured by timely prescription refills and used multivariable Cox proportional hazards models to assess the association between copayment amount and the risk of nonadherence. RESULTS: Ninety-four percent of women used the pill, and 6% used the patch or ring. Forty percent of patients had no copayment and 25% had a copayment of ≥$30. Nearly 75% of women were nonadherent during the study period. In 2013 and 2014, women with a copayment had a 9% increased risk of nonadherence (adjusted hazard ratio, 1.09; 95% confidence interval, 1.04, 1.14) compared with women with no copayment. CONCLUSIONS: Prescription copayments may serve as a barrier to adherence of pharmacy-dispensed contraception. Given recent changes to Affordable Care Act contraceptive coverage requirement, these findings can be used to support state-level and health system-level policies for no-cost contraception, and to determine the potential public health impact of this policy change.

[The use of free-of-charge prescription contraceptives among women : Results of a pilot project in the German federal state of Mecklenburg-Western Pomerania]. / Inanspruchnahme kostenfreier verschreibungspflichtiger Verhütungsmittel durch Frauen : Ergebnisse eines Modellprojekts in Mecklenburg-Vorpommern.

BACKGROUND: There is a connection between the receipt of unemployment benefits and the failure to use contraceptives in Germany. This study aims to understand the use of contraceptives among women entitled to unemployment benefits under the Sozialgesetzbuch II or XII (SGB II or SGB XII), prior and during an offer of contraceptives free of charge (CFOC). METHODS: The criteria for the use of CFOC (pill, intrauterine device, or ring) over a 12-month period were: age between 20 and 35 years, resident in predefined urban or rural postal codes in the German federal state of Mecklenburg-Western Pomerania, and participation in a self-administered survey. Data about participants' age, education, number of children, relationship status, period of payment according to SGB II or SGB XII, the use and barriers to use of contraceptives during every occurrence of sexual intercourse, as well as the kind of contraceptives used. RESULTS: From a total of 418 women: 40.9% were single-mothers, 39.0% did not graduate school, 21.1% were childless, and 57.9% had received unemployment benefits for at least three years. Further, 21.1% rated their type of contraceptive as "less safe" or "unsafe." The most commonly cited reasons for nonregular use of contraceptives were: they are too expensive or their use is forgotten. A change in contraceptives was made by 30.9% due to the offer of CFOC. The change was associated with the number of children and the exclusive use of less safe contraceptives. DISCUSSION: CFOC seems to be attractive, especially for women with children and those who receive long-term unemployment benefits. Changing demands concerning the safety of birth control during the lives of women should be considered in the discussion about common rules for the access to CFOC.