Mobile solutions to Empower reproductive life planning for women living with HIV in Kenya (MWACh EMPOWER): Protocol for a cluster randomized controlled trial.

BACKGROUND: Women living with HIV (WLWH) face unique reproductive health (RH) barriers which increase their risks of unmet need for contraception, contraceptive failure, unintended pregnancy, and pregnancy-related morbidity and mortality and may prevent them from achieving their reproductive goals. Patient-centered counseling interventions that support health care workers (HCWs) in providing high-quality RH counseling, tailored to the needs of WLWH, may improve reproductive health outcomes. METHODS AND DESIGN: We are conducting a non-blinded cluster randomized controlled trial (cRCT) of a digital health intervention for WLWH (clinicaltrials.gov #NCT05285670). We will enroll 3,300 WLWH seeking care in 10 HIV care and treatment centers in Nairobi and Western Kenya. WLWH at intervention sites receive the Mobile WACh Empower intervention, a tablet-based RH decision-support counseling tool administered at baseline and SMS support during two years of follow-up. WLWH at control sites receive the standard of care FP counseling. The decision-support tool is a logic-based tool for family planning (FP) counseling that uses branching logic to guide RH questions based on participants' reproductive life plans, tailoring counseling based on the responses. Follow-up SMSs are based in the Information-Motivation-Behavioral (IMB) Skills model of behavioral change and are tailored to participant characteristics and reproductive needs through separate SMS "tracks". Follow-up visits are scheduled quarterly for 2 years to assess plans for pregnancy, pregnancy prevention, and contraceptive use. The primary outcome, FP discontinuation, will be compared using an intent-to-treat analysis. We will also assess the unmet need for FP, dual method use, viral load suppression at conception and unintended pregnancy. DISCUSSION: The Mobile WACh Empower intervention is innovative as it combines a patient-centered counseling tool to support initial reproductive life decisions with longitudinal SMS for continued RH support and may help provide RH care within the context of provision of HIV care.

Community perceptions, beliefs and factors determining family planning uptake among men and women in Ekiti State, Nigeria: finding from a descriptive exploratory study.

OBJECTIVES: To examine family planning through the community's perception, belief system and cultural impact; in addition to identifying the determining factors for family planning uptake. DESIGN: A descriptive exploratory study. SETTING: Three communities were selected from three local government areas, each in the three senatorial districts in Ekiti State. PARTICIPANTS: The study was conducted among young unmarried women in the reproductive age group who were sexually active as well as married men and women in the reproductive age group who are currently living with their partners and were sexually active. MAIN OUTCOME MEASURES: Eight focus group discussions were conducted in the community in 2019 with 28 male and 50 female participants. The audio recordings were transcribed, triangulated with notes and analysed using QSR NVivo V.8 software. Community perception, beliefs and perceptions of the utility of family planning, as well as cultural, religious and other factors determining family planning uptake were analysed. RESULTS: The majority of the participants had the perception that family planning helps married couple only. There were diverse beliefs about family planning and mixed reactions with respect to the impact of culture and religion on family planning uptake. Furthermore, a number of factors were identified in determining family planning uptake-intrapersonal, interpersonal and health system factors. CONCLUSION: The study concluded that there are varied reactions to family planning uptake due to varied perception, cultural and religious beliefs and determining factors. It was recommended that more targeted male partner engagement in campaign would boost family planning uptake.

Women's experiences of postpartum contraceptive services when elective caesarean section is the method of birth: a qualitative study.

BACKGROUND: The unmet need for postpartum contraception is a global challenge. Postpartum placement of an intrauterine device (IUD) within 48 hours of vaginal delivery is available in many settings worldwide, but is not routinely practised in Sweden. To improve contraceptive services and facilitate the informed choice of IUD placement at the time of a caesarean section (CS), we performed this study to identify and describe women's experiences of contraceptive services before, during and after an elective CS. METHODS: A qualitative design and methodology was used. We interviewed 20 women aged 28-42 years who underwent elective CS in Sweden. Interviews were analysed using reflexive thematic analysis. RESULTS: The three main themes found were (1) receptivity to contraceptive counselling in the context of CS, (2) communication and decision-making about postpartum contraception before CS and (3) lack of support and guidance to receive contraceptive services before and after CS. The participants described readiness and interest regarding postpartum contraception. They prefered counselling from around 25 weeks of gestation. Despite this finding, antenatal communication and contraceptive decision-making seemed rare. Participants reported a lack of support and guidance which necessitated a need by women to navigate the contraceptive services themselves in order to receive information about contraception before CS and to receive postpartum support. CONCLUSIONS: Antenatal contraceptive counselling including information about IUD placement during CS was appreciated and welcomed by women with elective CS as their birth method. Most of the women whom we interviewed would prefer to receive contraception counselling on postpartum use during the second half of their pregnancy.

Impact of a post-partum family planning intervention on contraception and fertility in Tanzania: two-year follow-up of a cluster-randomised controlled trial.

PURPOSE: We evaluate contraceptive use and pregnancy two years following an intervention in Tanzania, which provided antenatal post-partum family planning counselling and post-partum intrauterine device (PPIUD) services following delivery. METHODS: We analyse data from five hospitals in Tanzania using a difference-in-difference cluster randomised design, with randomisation at the hospital level. We use women-level data collected at the index birth and a follow-up survey two years later among 6,410 women. Outcomes (overall modern contraceptive use, contraceptive type, pregnancy) are modelled with an intent-to-treat (ITT) approach using linear regression. We compare with the complier average causal effect (CACE) of the intervention among those counselled. RESULTS: The intervention increased long-term PPIUD use by 5.8 percentage points (95% CI: 0.7-11.2%) through substitution away from other modern methods. There was no impact on overall modern contraceptive prevalence or pregnancy. Only 29% of women reported receiving PPIUD counselling. When accounting for this in the CACE analysis we saw a larger impact with 25.7% percentage point increase in PPIUD use (95% CI: 22.7-28.6%). CONCLUSION: The intervention provided women an additional contraceptive choice, resulting in higher use of PPIUD over two years. Increase in PPIUD use was brought about by shifting methods, not creating new modern contraceptive users.

The post-partum family planning intervention in Tanzania offered women a new contraceptive option and increased sustained use of post-partum IUD. The intervention did not attract new modern contraception users and could have a greater impact if implemented more widely.

Experiences with family planning and abortion services during the Covid-19 pandemic: a qualitative study in Bangladesh, Iran and Netherlands.

OBJECTIVE: Access to family planning services is a human right that plays an essential role in society's health, particularly women's health. The COVID-19 pandemic has affected all aspects of human life including access to family planning services. Accordingly, the main goal of this study was to explore the experiences of women and service providers from the main challenges and obstacles of access to family planning services and abortion services in Bangladesh, Iran, and the Netherlands during the COVID-19 pandemic. METHODS: In this qualitative study, the data were collected through online, telephone, or in-person semi-structured interviews with key informants. Participants selected by purposive sampling method. The participants included women aged 15 to 49 (n = 63) and service providers (n = 54) in the 3 abovementioned countries. These individuals were included from October 2020 until December 2020. Conventional thematic analysis was employed to analyze the collected data. RESULTS: The main extracted themes were challenges (reduction of referral; disruption of access to services; insufficient knowledge; worries among staff; rising prices; and unavailability of some contraceptives), measures (time extension and visit scheduling; telephone, online, and door to door services; and support of the media) and recommendations (health facility improvements; free, online, and closer services; and ongoing trainings and awareness campaigns). CONCLUSION: The COVID-19 pandemic has affected family planning and reproductive health services in different ways and has uncovered existing inequalities in access to these services. However, in Iran, the reported challenges were also rooted in new population policies that have further limited access to family planning and abortion services.

ACCEPTANCE AND UTILIZATION OF MODERN FAMILY PLANNING METHODS AMONG WOMEN OF CHILD BEARING AGE IN RURAL COMMUNITIES OF NORTH-EASTERN NIGERIA.

Introduction: Modern family planning is one of the most "health-promoting" and cost-effective activities in public health promotion and has the potential to avert approximately 30% of maternal and 10% of child deaths. Family planning is an important preventive measure against maternal and child morbidity and mortality. It is an essential component of primary health care and reproductive health. It confers important health and development benefits to individuals, families, communities, and the nation at large. Objectives: The study examined the acceptance and utilization of modern family planning methods among women of childbearing age in Potiskum town of Yobe State, North-eastern Nigeria. Methodology: A descriptive cross-sectional study design was adopted for the study. A semi-structured questionnaire was used to collect data from 271 respondents comprising women of childbearing age (15-49 years) residing in Bolewa 'B', Yerimaram, and DogoNini wards of Potiskum town, Yobe State. A multi-stage sampling technique was used to select the participants for the study. Results: The findings of the study revealed that the women of child-bearing age in Potiskum town, Yobe State have a high level of knowledge on modern family planning methods (88.6%) with friends and relatives as the predominant source of information (60.4%). More than half of the respondents (54.2%) have good utilization of modern family planning with cultural and religious misconceptions playing vital roles. The unmet needs were found to be (37.4%). Established determinants of utilization of modern family planning services among the respondents include male noninvolvement, side effects, religion, and distance beyond 5km to a health facility. Conclusion: In conclusion, despite a good level of knowledge of modern contraceptives among the respondents, only half utilize the services. It is recommended among others that, there is a need for the government, through the Ministry of Health, to revive and support family planning education at both household and community levels that targets the woman and her partner. This could be undertaken through community mobilization and engagement using print and mass media, traditional leaders, community resource groups, market places as well as newsletters, posters, and social media.

Use of a hybrid digital training approach for hormonal IUD providers in Nigeria: results from a mixed method study.

BACKGROUND: In Nigeria, in-service trainings for new family planning (FP) methods have typically been conducted using a combination of classroom-based learning, skills labs, and supervised practicums. This mixed-methods study evaluated the feasibility, acceptability, provider competency, and costs associated with a hybrid digital and in-person training model for the hormonal intrauterine device (IUD). METHODS: The study was conducted in Enugu, Kano, and Oyo states, Nigeria, and enrolled FP providers previously trained on non-hormonal IUDs. Participants completed a digital didactic training, an in-person model-based practicum with an Objective Structured Clinical Examination (OSCE), followed by supervised provision of service to clients. Provider knowledge gains and clinical competency were assessed and described descriptively. Data on the feasibility, acceptability, and scalability of the approach were gathered from participating providers, clinical supervisors, and key stakeholders. Training costs were captured using an activity-based approach and used to calculate a cost per provider trained. All analyses were descriptive. RESULTS: Sixty-two providers took the hybrid digital training, of whom 60 (91%) were included in the study (n = 36 from public sector, n = 15 from private sector, and n = 9 both public/private). The average knowledge score increased from 62 to 86% pre- and post-training. Clinical competency was overall very high (mean: 94%), and all providers achieved certification. Providers liked that the digital training could be done at the time/place of their choosing (84%), was self-paced (79%), and reduced risk of COVID-19 exposure (75%). Clinical supervisors and Ministry of Health stakeholders also had positive impressions of the training and its scalability. The hybrid training package cost $316 per provider trained. CONCLUSIONS: We found that a hybrid digital training approach to hormonal IUD service provision in Nigeria was acceptable and feasible. Providers demonstrated increases in knowledge following the training and achieved high levels of clinical competency. Both providers and clinical supervisors felt that the digital training content was of high quality and an acceptable (sometimes preferable) alternative to classroom-based, in-person training. This study provided insights into a hybrid digital training model for a long-acting contraceptive, relevant to scale-up in Nigeria and similar settings.

Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review.

BACKGROUND: Demand generation aims to increase clients' desire to use family planning. The aim of this work was to systematically summarize strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning. METHODS: We searched electronic bibliographic databases from inception to October 2022. We included quantitative, qualitative, and mixed methods reports on demand generation strategies in family planning, regardless of country, language, publication status, or methodological limitations. We assessed abstracts, titles and full-text papers according to the inclusion criteria, extracted data, and assessed methodological quality of included reports. We used the convergent integrated approach and a deductive thematic synthesis to summarize demand generation themes and subthemes. We used the health system building blocks to synthesize the factors affecting implementation (barriers and facilitators). We used GRADE-CERQual to assess our confidence in the findings. RESULTS: Forty-six studies (published 1990-2022) were included: forty-one quantitative, one qualitative, and four mixed methods). Three were from one high-income country, and forty three from LMIC settings. Half of reports were judged to be of unclear risk of bias. There were unique yet interrelated strategies of scaling-up demand generation for family planning. Interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. Demand-side financing approaches probably increase awareness of contraceptives and the use of modern contraceptive methods among poor clients. Multifaceted Demand generation approaches probably improve adoption, coverage and sustainability of modern methods use. Factors that influence the success of implementing these strategies include users knowledge about family planning methods, the availability of modern methods, and the accessibility to services. CONCLUSIONS: Demand generation strategies may function independently or supplement each other. The myriad of techniques of the different demand generation strategies, the complexities of family planning services, and human interactions defy simplistic conclusions on how a specific strategy or a bundle of strategies may succeed in increasing and sustaining family planning utilization. TRIAL REGISTRATION: Systematic review registration: Center for Open Science, osf.io/286j5.

Family planning could prevent one third of maternal deaths by allowing women to delay motherhood, avoid unintended pregnancies and subsequent abortions. Demand generation is one of the critical factors for increasing coverage and sustainability of family planning programs. Demand generation activities aim to increase clients' desire to use family planning by changing their attitudes or perceptions about FP or increasing their awareness or knowledge about FP methods and also by improving access to contraceptive services. Many demand generation activities also aim to shift social and cultural norms to affect individual behavior change. Scaling up demand generation and ensuring that demand for family planning is satisfied is essential for achieving universal access to reproductive health-care services. We systematically searched for and summarized reports of strategies to scale up demand generation for family planning. Available evidence shows that interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. The effect of new media is uncertain. Demand-side financing approach probably increase awareness of contraceptives and the use of modern contraceptive methods among poor women. The most apparent factors influencing the success of implementing these strategies include knowledge about family planning methods, especially regarding side effects and health concerns, the availability of modern contraceptive methods, and the accessibility to family planning services.

Mobile Applications for Family Planning.

INTRODUCTION: Family planning reduces maternal and child morbidity and mortality by promoting pregnancy spacing. The postpartum period is an ideal time for patients to access family planning services. Mobile applications can aid in accessing information about family planning. METHODS: A review was conducted on PubMed from 2012 to 2022, using keywords "mobile app," "family planning, "contraception,". RESULTS: Numerous studies have found as randomized controlled trials evaluating the use of mobile applications such as Decide + Be Ready in contraception. Other studies focused on healthcare providers' use of mobile apps for postpartum care and monitoring contraceptive methods. CONCLUSION: Mobile applications in family planning can assist healthcare providers in clinical care delivery is feasible and acceptable, saving time and providing accessible information.

Understanding of Lactational Amenorrhea As a Contraceptive Method Among U.S. Pregnant Women.

Introduction: The lactational amenorrhea method (LAM) of postpartum contraception is more effective than typical use of condoms or birth control pills. However, LAM may be underutilized due to incomplete perinatal counseling. Methods: We compared perceptions of the effectiveness of postpartum contraceptives including LAM among U.S.-born nulliparous pregnant women recruited using social media for a trial (NCT04601987). We used descriptive statistics to summarize data. Results: Of 760 individuals screened, 627 were invited to participate, and 451 (72%) were enrolled. Most (81%) had a college degree; 79% intended to breastfeed for at least 1 month. Only 8% believed exclusive breastfeeding reduces the chance of pregnancy "a lot" within 6 months of delivery and 2% indicated that exclusive breastfeeding is typically more effective than birth control pills or condoms. Compared with those planning to use other postpartum contraceptives, the 17% of respondents who planned to use LAM were more likely to know that breastfeeding delays return of menses (84% versus 44%, p ≤ 0.0001) and provides protection from pregnancy until menses return (54% versus 22%, p ≤ 0.0001). Although 25% of those planning to use LAM believed exclusive breastfeeding reduces pregnancy risk by "a lot," only 5% thought LAM is more effective than birth control pills and only 9% thought that it is more effective than condoms. Conclusions/Implications: First-time U.S. mothers are often unaware of breastfeeding's effects on menses and fertility. Clinicians providing counseling about postpartum contraceptive options should include more information on LAM.

Trends and Determinants of Non-Utilization of Modern Contraception in Ekiti State, Nigeria: A Ten-Year Review.

BACKGROUND: An increase in correct usage of modern contraception is vital in reducing the maternal mortality ratio and Under-5 mortality, leading towards the achievement of Sustainable Development Goal 3. Our study examined the trends and factors affecting non-utilization of modern contraceptives over a 10-year period in Ekiti State, Nigeria. METHODOLOGY: This study used data from three consecutive National Demographic Health Surveys (NDHS) - 2008, 2013, and 2018 - with a weighted sample size of 1,357 women of reproductive age (15-49 years). Data on contraceptive use on these women, provided by the NDHS, were extracted and analysed using IBM SPSS version 25. The sample was weighted to adjust for disproportionate sampling and non-response. Pearson's chi-square and binary logistic regression were used to assess the factors associated with non-utilization of modern contraceptives. RESULTS AND FINDINGS: The mean age of the women was 30 years. Modern contraceptive use increased from 13.1% in 2008 to 23.0% in 2018, while unmet need for modern contraceptives decreased from 84.8% in 2008 to 75.4% in 2018. Identified predictors of non-utilization of modern contraceptive were age 20-24 years [aOR=0.33, 95%CI=0.19-0.59], 25-29 years [aOR=0.34, 95%CI=0.18-0.64], 30-34 years [aOR=0.46, 95%CI=0.22-0.94], 35-39 years [aOR=0.29, 95%CI=0.14-0.61] and 40-44 years [aOR=0.37, 95%CI=0.17-0.80] compared to age 15-19 years; living in urban areas [aOR=0.72, 95%CI=0.53-0.98] compared to in rural areas; higher level of education [aOR=0.46, 95%CI=0.21-0.98] compared to no education; and desire for more children [aOR=0.48, 95%CI=0.32-0.73] compared to not wanting more children. CONCLUSION: Although contraceptive usage increased over time, the factors associated with non-utilization were being an adolescent, living in a rural area, lower level of education, and desire for more children.

Why intrauterine device (IUD) utilization is low in southwestern Ethiopia. A mixed-method study.

INTRODUCTION: An intrauterine device (IUD) is a highly effective long-acting and reversible contraceptive method widely available around the world. However, only a small proportion of women in developing countries, including Ethiopia, are currently using the method. Therefore, this study aimed to identify why IUD utilization is low in southwestern Ethiopia. MATERIAL AND METHODS: A mixed-method study involving health facilities and communities was conducted. The focus group discussions and key informant interviewees for the qualitative study were selected purposively, whereas 844 women family planning users were selected using systematic random sampling from November 1-30, 2020. Quantitative data was collected using Open Data Kit and analyzed using Stata version 16.0. Multivariable logistic regression analyses were done to identify significant factors influencing IUD use. The qualitative data were tape-recorded, transcribed, and finally, thematic analyses were done. RESULTS: A total of 784 participants were involved in the study yielding a response rate of 92.9%. Among all respondents, only 1.3%, 2.4%, and 30.0% had been using an IUD, preferred an IUD, and had the intention to use an IUD, respectively. The main reported barriers to use an IUD among qualitative participants were fear of side-effects, religious prohibitions of contraception use, husband disapproval, lack of training by health workers, misconceptions, and longer duration of use. IUD information (AOR = 2.19 [CI: 1.56-3.08]), and rich wealth status (AOR = 1.70 [CI: 1.13-2.56]) were associated with the intention to continue or start to use an IUD. CONCLUSIONS: IUD use and information on IUDs in the study area was very low. Information about IUDs, wealth status, and partner disapproval were determinant factors for intention to use an IUD. Thus, a regular awareness creation program using accessible media platforms by the government and stakeholders on IUD use is necessary to provide reliable information to the community and resolve misconceptions. In addition, women's empowerment to balance partner dominance on decision-making of contraception use and health care worker training on long-acting reversible contraceptives (LARCs) to increase access to LARC services are necessary to increase uptake of LARCs in general and of IUDs, in particular in the study regions.

Evaluation of the effect of the Momentum project on family planning outcomes among first-time mothers aged 15-24 years in Kinshasa, DRC.

OBJECTIVES: This article presents the effect of Momentum, a nursing student-led community-based service delivery project, on postpartum family planning (FP) outcomes among first-time mothers in Kinshasa, Democratic Republic of the Congo. STUDY DESIGN: We employed a quasi-experimental design, with three intervention and three comparison health zones (HZ). Data were collected through interviewer-administered questionnaires in 2018 and 2020. The sample consisted of 1927 nulliparous women aged 15-24 years who were 6 months pregnant at baseline. Random effects and treatment effects models were used to assess the effect of Momentum on 14 postpartum FP outcomes. RESULTS: The intervention group was associated with a unit increase of 0.6 (95% confidence interval [CI]: 0.4, 0.8)) in contraceptive knowledge and personal agency (95% CI: 0.3, 0.9), a unit decrease of 0.9 (95% CI: -1.2, -0.5) in the number of FP myths/misconceptions endorsed, and percentage point increases of 23.4 (95% CI: 0.2, 0.3) in FP discussion with a health worker, 13.0 (95% CI: 0.1, 0.2) in obtaining a contraceptive method within 6 weeks of delivery, and 13.3 (95% CI: 0.1, 0.2) in modern contraceptive use within 12 months of delivery. Intervention effects included percentage point increases of 5.4 (95% CI: 0.0, 0.1) in partner discussion and 15.4 (95% CI: 0.1, 0.2) in perceived community support for postpartum FP use. The level of exposure to Momentum was significantly associated with all behavioral outcomes. CONCLUSIONS: The study demonstrated the effect of Momentum on increased postpartum FP-related knowledge, perceived norms, personal agency, partner discussion, and modern contraceptive use. IMPLICATIONS: Community-based service delivery by nursing students can potentially lead to improved postpartum FP outcomes among urban adolescent and young first-time mothers in other provinces of the Democratic Republic of the Congo and other African countries.

"So let me give you money, you give me what I want": decision-making priorities around contraceptive method and source choice among young women in Kenya.

BACKGROUND: Many factors influence young women's choice of contraceptive methods and where to source them, yet less is known about whether one of these choices (method or source) is prioritized and the relationship between these choices. This study qualitatively explored decision-making around contraceptive method and source choice among young women in Kenya. METHODS: In August-September 2019, 30 in-depth interviews were conducted with women ages 18-24 who had used two or more contraceptive methods and resided in three counties: Nairobi, Mombasa or Migori. Participants were recruited from public and private health facilities and pharmacies. Interview guides captured information about decision-making processes for each contraceptive method the respondent had ever used. Responses were audio-recorded, transcribed, translated into English, coded, and analyzed thematically. RESULTS: The majority of respondents knew which method they wanted to use prior to seeking it from a source. This was true for all types of methods that women ever used. Of the small number of respondents who selected their source first, most were in the post-partum period or experiencing side effects and sought counseling at a source before choosing a method. CONCLUSIONS: This study highlights the importance of providing young women with high quality counseling that provides full information about contraceptive options and addresses that young women's needs vary along the reproductive health continuum of care. This will ensure that young women have information to inform future contraceptive decision-making prior to seeking care.

Reassessing the level and implications of male involvement in family planning in Indonesia.

BACKGROUND: Although there is global recognition of the importance of involving men in family planning and reproductive health matters, this issue has received insufficient attention in many countries. The present study sought to characterize married Indonesian males as to their level of involvement in family planning, identify the correlates thereof and assess the implications of male involvement for unmet need for family planning. METHODS: A mixed methods research design was used. The main source of quantitative data was 2017 Indonesian Demographic Health Survey (IDHS) data from 8,380 married couples. The underlying "dimensions" of male involvement were identified via factor analysis. The correlates of male involvement were assessed via comparisons across the four dimensions of male involvement identified in the factor analysis. Outcomes were assessed by comparing women's and couple's unmet need for family planning for the four underlying dimensions of male involvement. Qualitative data were collected via focus group discussions with four groups of key informants. RESULTS: Indonesian male involvement as family planning clients remains limited, with only 8% of men using a contraceptive method at the time of the 2017 IDHS. However, factor analyses revealed three other independent "dimensions" of male involvement, two of which (along with male contraceptive use) were associated with significantly lower odds of female unmet need for family planning. Male involvement as clients and passive male approval of family planning, which in Indonesia empowers females take action to avoid unwanted pregnancies, were associated with 23% and 35% reductions in female unmet need, respectively. The analyses suggest that age, education, geographic residence, knowledge of contraceptive methods, and media exposure distinguish men with higher levels of involvement. Socially mandated gender roles concerning family planning and perceived limited programmatic attention to males highlight the quantitative findings. CONCLUSIONS: Indonesian males are involved in family planning in several ways, although women continue to bear most of the responsibility for realizing couple reproductive aspirations. Gender transformative programming that addresses broader gender issues and targets priority sub-groups of men as well as health service providers, community and religious leaders would seem to be the way forward.

Despite global recognition of the importance of involving men in family planning and women's health matters, this matter has received insufficient the attention in many countries. The present study sought to characterize married Indonesian males as to their level of involvement in family planning, identify correlates of male involvement, and assess the implications of varying levels of male participation for family planning outcomes.The study used a mixed methods research design. The main source of quantitative data was a 2017 Indonesian Demographic Health Survey (IDHS) data set of 8,380 married couples. Factor analyses were undertaken to identify the underlying dimensions of male involvement. The correlates of male involvement were assessed via comparisons across the four underlying dimensions of male involvement group identified in the factor analysis. Outcomes were assessed by comparing women's and couple's unmet need for family planning for the four underlying dimensions of male involvement. Qualitative data were collected via focus group discussions with four groups of key informants.The study found that male involvement as family planning clients remains limited, with only 8% of men using contraceptive methods themselves. However, Indonesian men are involved in other ways such via approval of family planning and active communications that contribute to lower female unmet need for family planning. The analyses suggest that age, education, geographic residence, knowledge of contraceptive methods, and media exposure distinguish men with higher versus lower levels of involvement. The most important contribution of males to realizing couple-level desires to limit or space births is via the approval of family planning, which empowers females take action to avoid unwanted pregnancies. Socially mandated gender roles concerning family planning and perceived limited programmatic attention to males are highlighted in the quantitative findings.In the way of an overall conclusion, Indonesian males are involved in family planning in several ways, although women continue to bear most of the responsibility for realizing couple reproductive aspirations. Gender transformative programming that addresses broader gender issues and targets priority sub-groups of men as well as health service providers, community and religious leaders would seem to be the way forward.

The association between quality of contraceptive counseling and selection of contraceptive method post-counseling among women in Ethiopia.

OBJECTIVES: To better understand the relationship between high-quality contraceptive counseling and met family planning needs, we examined the association between quality of counseling and selection of a method postvisit among women requesting contraception in Ethiopia. STUDY DESIGN: We used post-counseling survey data from women receiving care in public health centers and nongovernmental clinics in three regions in Ethiopia. Among women whose reason for visit was requesting a contraceptive method, we examined the association between scores on the validated quality of contraceptive counseling (QCC) scale and subscales and selection of a method post-counseling (primary analysis) and type of method selected (secondary analysis). We conducted mixed-effects multivariable logistic regression for the primary analysis and multinomial regression for the secondary analysis. RESULTS: There was a nonsignificant increase in odds of selecting contraception with increasing total QCC scale scores (adjusted odds ratio [aOR] 2.35, 0.43-12.95). However, among women experiencing no disrespect and abuse, there was increasing odds of selecting contraception (aOR 3.46, 95% CI 1.09-10.99) and likelihood of selecting injectable contraception (adjusted relative risk ratio 4.27, 95% CI 1.34-13.60) compared to women experiencing disrespect and abuse. Additionally, 168 (32.1%) of women felt pressured by their provider to use a certain method of which>50% selected long-acting reversible contraception. CONCLUSIONS: Increasing QCC is associated with selecting contraception among women requesting contraception. Additionally, probing for negative experiences can reveal feelings of disrespect and abuse that could lead women to avoid selecting contraception or feeling pressured to use methods heavily promoted by providers. IMPLICATIONS: Our study assesses contraceptive counseling quality using a validated tool with items on provider pressure and other forms of disrespect and abuse; findings highlight the importance of respectful treatment in meeting women's needs and the potential influence of disrespect on decision to select contraception and type of method selected.

A Quality Improvement Innovation for Reproductive Health Planning in the Time of COVID.

OBJECTIVES: To see if an outreach approach with telehealth is feasible and acceptable to patients to talk about their reproductive health; and as a secondary outcome, capture data on time spent on the visit and what kind of information was discussed. METHODS: A registry was created from three family physicians' panels of all adult patients with anticipated ability to become pregnant ages 18-45 who had not had a documented reproductive health discussion in the previous 6 months. Using that registry, outreach was performed to schedule a telehealth visit to discuss their reproductive health with their primary care provider. The visit was standardized using the One Key Question approach. For patients who agreed to participate in the research, the patient completed a survey about their experience. The provider also completed a survey on the time spent and the issues addressed. RESULTS: Two hundred and six patients were called. Ninety patients (44%) could not be reached. Of the remaining patients, 34 scheduled either a telehealth or in-person visit and 7 also agreed to participate in the survey. New information was uncovered in the visit in 86% of participants. The most common need uncovered during the visit was unrelated medical needs (71%), followed by preconception health education/advice (43%) and contraception needs/counseling (29%). Most participants found the telehealth visit valuable. CONCLUSIONS: An outreach methodology can uncover unmet health needs, both reproductive and otherwise. We found that people who had the visit often needed something, but a majority of patients declined the visit saying that they did not think they needed it. It is possible that patients are not aware of the value of reproductive health discussions, and therefore clinicians need to take every opportunity to have these discussions whenever possible, whether through outreach or inreach (during already scheduled visits).

Reproductive issues and multiple sclerosis: 20 questions.

Multiple sclerosis (MS) is commonly diagnosed in young adults during their reproductive years. Consequently, concerns about family planning and MS management related to pregnancy and breastfeeding are often encountered in clinical practice. Pregnancy itself is not harmful for women with MS. However, disease-modifying therapies (DMTs) have implications for reproductive planning, including stopping treatment while trying to conceive and during pregnancy, as well as managing fetal risks. People with MS and their care team must engage in collaborative decision-making before, during, and after pregnancy. Based on the results of a consensus-building initiative, answers are provided to 20 frequently asked questions regarding the management of MS during pregnancy planning, pregnancy, and the postpartum period.

'The wife should do as her husband advises': Understanding factors influencing contraceptive use decision making among married Pakistani couples-Qualitative study.

This paper explores the perceptions and attitudes of married couples which prevent them from using modern contraceptive for purpose of family planning, based on semi-structured interviews with 16 married couples from rural Pakistan. This study, with married couples, not using any modern contraceptives, discussed issues of spousal communication and religious norms using qualitative methods. Despite near universal knowledge of modern contraceptives among married Pakistani women, the use continues to be low, with high unmet need. Understanding the couple context about reproductive decision making, pregnancy and family planning intentions is imperative to helping individuals fulfil their reproductive desires. Married couples may have varying intentions and desires about family size; a lack of alignment between partners may lead to unintended pregnancies and affect uptake and use of contraception. This study specifically explored the factors which prevent married couples from using LARCs for family planning, despite their availability, at affordable prices in the study area of rural Islamabad, Pakistan. Findings show differences between concordant and discordant couples regarding desired family size, contraceptive communication and influence of religious beliefs. Understanding the role that male partners play in family planning and use of contraceptives is important in preventing unintended pregnancies and improving service delivery programmes. This study also helped identify the challenges married couples, particularly men have in understanding family planning and contraceptive use. The results also show that while men's participation in family planning decision making is limited, there is also a lack of programs and interventions for Pakistani men. The study findings can support development of appropriate strategies and implementation plans.