Dynamic stagnation: reasons for contraceptive non-use in context of fertility stall.

Background: While most countries have experienced reductions in the total fertility rate (TFR), there are countries where the fertility transition has not begun and others where the fertility transition has stalled with TFR still well above replacement level.  We use these contexts of "fertility stagnation" to explore reasons behind contraceptive non-use among women who desire to delay or avoid a future birth.  Specifically, we explore whether women's reasons for not using contraception are stagnant as the population-level indicator, TFR, suggests or are more dynamic. This nuanced understanding can inform programmatic direction for countries especially in need.  Methods: Using Demographic and Health Survey (DHS) data from the two most recent surveys of ten study countries-five countries that have not yet experienced a fertility transition ("pre-transitional") and five countries that began the fertility transition but stalled ("transitional")-we explore trends in reasons for non-use.  Results: We find that that reasons for non-use are changing. Specifically, in pre-transition study countries, women are increasingly citing attitudes opposing contraception as reasons for non-use.  In transition countries, women are increasingly citing reasons related to service quality and method side effects. Perceived low fecundability is increasingly cited among both pre-transition and transition study countries. Geographical access and cost are not prominent frequently cited at either time point.  Conclusions: These findings highlight the need for prioritized programmatic attention aimed at: reducing opposition to contraception in pre-transitional countries; improving service quality and addressing issues of side-effects, both experienced and perceived, in transitional countries; and addressing fecundability perceptions in both types of country contexts.  We remind policy makers that even in contexts of fertility stagnation, underlying attitudes, norms, and barriers to contraceptive uptake are shifting.  Lack of change at the population-level can mask important changes at the individual-level that must be accounted for in program development and implementation.

Monitoring Progress in Equality for the Sustainable Development Goals: A Case Study of Meeting Demand for Family Planning.

OBJECTIVES: Equality is a central component of the Sustainable Development Goals (SDGs). We took one SDG indicator and benchmark-percent of family planning demand met with modern contraceptives, with a benchmark of at least 75% in all countries-as a case study to illuminate recommendations for monitoring equality. Specifically, we assessed levels, patterns, and trends in disparity by key background characteristics and identified disparity measures that are programmatically relevant and easy to interpret. METHODS: Data were from the Demographic and Health Surveys in 55 countries that have conducted at least 2 surveys since 1990. We calculated absolute difference among subgroups, disaggregated by age, education, household wealth quintile, urban/rural residence, subnational region/administrative unit, and marital status. Our unit of analysis was survey, and we conducted largely descriptive analyses. To understand trends in disparity, we used a fixed-effect linear regression model to estimate an annual rate of change in absolute differences. RESULTS: A significant level of disparity existed across various background characteristics, ranging from a median difference of 5 percentage points by marital status to 32 percentage points by administrative unit. On average across the study countries, national level of met demand has increased over time while disparity has declined in most disaggregates including by education, wealth, residence, and age. We found statistically significant positive correlations among 4 disparity measures-education, wealth, residence, and administrative unit. Disparities by wealth quintile were easiest to interpret over time and across countries. CONCLUSIONS: At the global level, we recommend monitoring disparity in met demand by wealth quintile, which is strongly correlated with disparity by education, residence, and region and comparable across countries and over time. For monitoring by individual countries and for programmatic purposes, we further recommend monitoring disparity by first-level administrative unit, which can provide direct programmatic relevance.

A systematic review of Demographic and Health Surveys: data availability and utilization for research.

OBJECTIVE: To systematically review the public health literature to assess trends in the use of Demographic and Health Survey (DHS) data for research from 1984 to 2010 and to describe the relationship between data availability and data utilization. METHODS: The MEASURE DHS web site was searched for information on all population-based surveys completed under the DHS project between 1984 and 2010. The information collected included the country, type of survey, survey design, fieldwork period and certain special features, such as inclusion of biomarkers. A search of PubMed was also conducted to identify peer-reviewed articles published during 2010 that analysed DHS data and included an English-language abstract. Trends in data availability and in the use of DHS data for research were assessed through descriptive, graphical and bivariate linear regression analyses. FINDINGS: In total, 236 household surveys under the DHS project were completed across 84 countries during 2010. The number of surveys per year has remained constant, although the scope of the survey questions has expanded. The inclusion criteria were met by 1117 peer-reviewed publications. The number of publications has increased progressively over the last quarter century, with an average annual increment of 4.3 (95% confidence interval, CI: 3.2-5.3) publications. Trends in the number of peer-reviewed publications based on the use of DHS data were highly correlated with trends in funding for health by the Government of the United States of America and globally. CONCLUSION: Published peer-reviewed articles analysing DHS data, which have increased progressively in number over the last quarter century, have made a substantial contribution to the public health evidence base in developing countries.

Meeting the health information needs of health workers: what have we learned?

The information challenges facing health workers worldwide include lack of routine systems for seeking and sharing information, lack of high-quality and current health information, and lack of locally relevant materials and tools. This issue of Journal of Health Communication presents three studies of health information needs in India, Senegal, and Malawi that demonstrate these information challenges, provide additional insight, and describe innovative strategies to improve knowledge and information sharing. Results confirm that health workers' information needs differ on the basis of the level of the health system in which a health worker is located, regardless of country or cultural context. Data also reveal that communication channels tailored to health workers' needs and preferences are vital for improving information access and knowledge sharing. Meetings remain the way that most health workers communicate with each other, although technical working groups, professional associations, and networks also play strong roles in information and knowledge sharing. Study findings also confirm health workers' need for up-to-date, simple information in formats useful for policy development, program management, and service delivery. It is important to note that data demonstrate a persistent need for a variety of information types--from research syntheses, to job aids, to case studies--and suggest the need to invest in multifaceted knowledge management systems and approaches that take advantage of expanding technology, especially mobile phones; support existing professional and social networks; and are tailored to the varying needs of health professionals across health systems. These common lessons can be universally applied to expand health workers' access to reliable, practical, evidence-based information.