Incorporating Method Dissatisfaction into Unmet Need for Contraception: Implications for Measurement and Impact.

While unmet need for contraception is commonly used to assess programmatic needs, it inadequately captures the complexity of fertility and contraceptive preferences, including women's satisfaction with their contraceptive method. In their 2019 commentary, Sarah Rominski and Rob Stephenson propose reclassifying dissatisfied current users as having an unmet need for contraception. As revising the current definition based on their proposal would require significant investment to update survey and monitoring systems, understanding the potential impact on current estimates of unmet need is critical. We estimated the impact of this approach in a Kenyan cohort of modern contraceptive users. We found the prevalence of method dissatisfaction ranges from 6.6% (95% confidence interval [CI] 5.6-7.8%) to 18.9% (95% CI 17.1-20.9%); if applied nationally, this results in a large (approximately 25-70%) increase in Kenya's current estimate of unmet need for any contraception. Our findings suggest a large impact on unmet need estimates for equivalent populations. Overall, we advocate for better measurements of method satisfaction and acceptability, with metrics developed that are robust to socioeconomic gradients and validated in low- and middle-income settings to ensure women's contraceptive needs are captured equitably.

Modern contraceptive use, unmet need, and demand satisfied among women of reproductive age who are married or in a union in the focus countries of the Family Planning 2020 initiative: a systematic analysis using the Family Planning Estimation Tool.

BACKGROUND: The London Summit on Family Planning in 2012 inspired the Family Planning 2020 (FP2020) initiative and the 120×20 goal of having an additional 120 million women and adolescent girls become users of modern contraceptives in 69 of the world's poorest countries by the year 2020. Working towards achieving 120 × 20 is crucial for ultimately achieving the Sustainable Development Goals of universal access and satisfying demand for reproductive health. Thus, a performance assessment is required to determine countries' progress. METHODS: An updated version of the Family Planning Estimation Tool (FPET) was used to construct estimates and projections of the modern contraceptive prevalence rate (mCPR), unmet need for, and demand satisfied with modern methods of contraception among women of reproductive age who are married or in a union in the focus countries of the FP2020 initiative. We assessed current levels of family planning indicators and changes between 2012 and 2017. A counterfactual analysis was used to assess if recent levels of mCPR exceeded pre-FP2020 expectations. FINDINGS: In 2017, the mCPR among women of reproductive age who are married or in a union in the FP2020 focus countries was 45·7% (95% uncertainty interval [UI] 42·4-49·1), unmet need for modern methods was 21·6% (19·7-23·9), and the demand satisfied with modern methods was 67·9% (64·4-71·1). Between 2012 and 2017 the number of women of reproductive age who are married or in a union who use modern methods increased by 28·8 million (95% UI 5·8-52·5). At the regional level, Asia has seen the mCPR among women of reproductive age who are married or in a union grow from 51·0% (95% UI 48·5-53·4) to 51·8% (47·3-56·5) between 2012 and 2017, which is slow growth, particularly when compared with a change from 23·9% (22·9-25·0) to 28·5% (26·8-30·2) across Africa. At the country level, based on a counterfactual analysis, we found that 61% of the countries that have made a commitment to FP2020 exceeded pre-FP2020 expectations for modern contraceptive use. Country success stories include rapid increases in Kenya, Mozambique, Malawi, Lesotho, Sierra Leone, Liberia, and Chad relative to what was expected in 2012. INTERPRETATION: Whereas the estimate of additional users up to 2017 for women of reproductive age who are married or in a union would suggest that the 120 × 20 goal for all women is overly ambitious, the aggregate outcomes mask the diversity in progress at the country level. We identified countries with accelerated progress, that provide inspiration and guidance on how to increase the use of family planning and inform future efforts, especially in countries where progress has been poor. FUNDING: The Bill & Melinda Gates Foundation, through grant support to the University of Massachusetts Amherst and Avenir Health.

Contraceptive Practice in Sub-Saharan Africa.

Forty eight of the African continent's 54 sovereign states are located in the Sub-Saharan Africa (SSA) region, with the government of each defining and shaping its own health services and delivery systems. This paper reviews the trends and patterns of contraceptive practice in the region. Using survey data available from the Demographic and Health Surveys and Performance Monitoring and Accountability 2020, the study finds modern contraceptive practice to be on the rise overall but with much geographic variation. The contraceptive methods most frequently used are injectables and, more recently, implants. Higher levels of use are observed among unmarried sexually active than married females. Although use is rising, contraceptive discontinuation rates are also high. Recent program initiatives discussed include expanding long-acting contraceptive options, promoting and delivering contraceptive methods in the postpartum period, and relying on community health workers for contraceptive outreach and service delivery. SSA's family planning situation remains challenged by weak health systems which must address competing priorities to manage disease prevention as well as primary health care. Increasing investments in family planning delivery in many SSA countries, however, augur for continued rapid uptake of modern contraception, possibly matching if not outpacing the record of other regions.

Impact of family planning programs in reducing high-risk births due to younger and older maternal age, short birth intervals, and high parity.

Several studies show that maternal and neonatal/infant mortality risks increase with younger and older maternal age (<18 and >34 years), high parity (birth order >3), and short birth intervals (<24 months). Family planning programs are widely viewed as having contributed to substantial maternal and neonatal mortality decline through contraceptive use--both by reducing unwanted births and by reducing the burden of these high-risk births. However, beyond averting births, the empirical evidence for the role of family planning in reducing high-risk births at population level is limited. We examined data from 205 Demographic and Health Surveys (DHS), conducted between 1985 and 2013, to describe the trends in high-risk births and their association with the pace of progress in modern contraceptive prevalence rate (yearly increase in rate of MCPR) in 57 developing countries. Using Blinder-Oaxaca decomposition technique, we then examine the contributions of family planning program, economic development (GDP per capita), and educational improvement (secondary school completion rate) on the progress of MCPR in order to link the net contribution of family planning program to the reduction of high-risk births mediated through contraceptive use. Countries that had the fastest progress in improving MCPR experienced the greatest declines in high-risk births due to short birth intervals (<24 months), high parity births (birth order >3), and older maternal age (>35 years). Births among younger women <18 years, however, did not decline significantly during this period. The decomposition analysis suggests that 63% of the increase in MCPR was due to family planning program efforts, 21% due to economic development, and 17% due to social advancement through women's education. Improvement in MCPR, predominately due to family planning programs, is a major driver of the decline in the burden of high-risk births due to high parity, shorter birth intervals, and older maternal age in developing countries. The lack of progress in the decline of births in younger women <18 years of age underscores the need for more attention to ensure that quality contraceptive methods are available to adolescent women in order to delay first births. This study substantiates the significance of family planning programming as a major health intervention for preventing high-risk births and associated maternal and child mortality, but it highlights the need for concerted efforts to strengthen service provision for adolescents.

Voluntary, human rights-based family planning: a conceptual framework.

At the 2012 Family Planning Summit in London, world leaders committed to providing effective family planning information and services to 120 million additional women and girls by the year 2020. Amid positive response, some expressed concern that the numeric goal could signal a retreat from the human rights-centered approach that underpinned the 1994 International Conference on Population and Development. Achieving the FP2020 goal will take concerted and coordinated efforts among diverse stakeholders and a new programmatic approach supported by the public health and human rights communities. This article presents a new conceptual framework designed to serve as a path toward fulfilling the FP2020 goal. This new unifying framework, which incorporates human rights laws and principles within family-planning-program and quality-of-care frameworks, brings what have been parallel lines of thought together in one construct to make human rights issues related to family planning practical.

Developing the "120 by 20" goal for the Global FP2020 Initiative.

This report describes the purpose for developing a quantitative goal for the London Summit on Family Planning held in July 2012, the methodology behind its formulation, and the lessons learned in the process. The London Summit has evolved into the global initiative known as FP2020, and the goal has become "120 by 20," or reaching 120 million additional users of modern contraceptive methods by 2020 in the world's poorest countries. The success of FP2020 will first be evaluated on the basis of quantitative verification to determine that the "120 by 20" goal was reached. More important, however, is the extent to which the goal today serves as a global rallying cry to mobilize resources and leadership around current family planning programs, with a focus on voluntary family planning and quality of care, and with an emphasis on meeting girls' and women's unmet needs and their right to practice contraception. We hope this article provides greater transparency and understanding of the FP2020 goal, and that the global goal spurs annual monitoring of progress toward national goals in the world's poorest countries.

A strategy for reducing maternal and newborn deaths by 2015 and beyond.

BACKGROUND: Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030. DISCUSSION: The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact. SUMMARY: Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.