Evaluation of Emergency Contraceptive Pill Use with Health Management Information Systems Data in Pakistan.

According to the WHO, all clients should have access to a range of contraceptive methods, including at least one short-term, one long-term, one permanent, and one emergency method of contraception. While there are data on the contraceptive method mix available for many low- and middle-income countries, there are limited data on emergency contraception (EC). This is likely due to some surveys not routinely collecting this information, how survey questions are asked, dual method use, and/or low levels of reported use of EC pill (ECP). Even with low reported use in surveys, contraceptive social marketing statistics from DKT International. show a trend in recent years of increasing product sales of ECPs. To understand a more complete scope of ECP use, we use Pakistan as a case study and analyze Pakistan's Demographic Health Survey (DHS) surveys and Pakistan's Contraceptives Logistics Management Systems. Based on commodities dispensed data for ECPs in 2021, about 0.4 percent of all married women in Pakistan use ECPs. While there is currently a small proportion of women, it is growing and the use of ECPs is not zero as indicated by the DHS. Therefore, where available, countries should review their health management information systems data alongside survey data for ECP use.

Women living with their mothers-in-law.

Background Many studies have documented the impacts mothers-in-law have on daughters-in-law living in the same household, but few have quantified the scale of this co-residence.   This study aims to estimate the proportion of married women living with their mothers-in-law across countries and time.  Methods Using household rosters from 250 Demographic and Health Surveys in 75 countries, this paper uses the "relationship to head of household" question to identify households where married women live with their mothers-in-law.  For select countries with large changes, we decompose changes in rates into changes in the age structure of married women and the rate of women living with their mothers-in-law by age. Results This paper finds large variation in family structure around the globe, from 1% of married women in Rwanda to 49% in Tajikistan living with their mother-in-law.  Many countries with high co-residence in the 1990s continue to see high and increasing numbers today, especially in Central and Southern Asia, while some North and sub-Saharan African countries experienced substantial declines.  Decomposing changes by age and rates shows that changes in the age structure of married women is not driving changes in co-residence, but rather the rates are changing across age groups.  Conclusions These findings show the large variation in women living with their mothers-in-law across the globe.  The authors provide publicly available code and future research ideas to encourage others to further our understanding of the impact of living with her mother-in-law on a woman's life.

Family Planning During and After the West African Ebola Crisis.

The West African Ebola outbreak of 2013-2016 had the potential to devastate family planning programs in affected countries, which had made great progress in years prior. We examine monthly provision of family planning service statistics from government sources for Liberia and Sierra Leone from 6 months before the first Ebola case to 24 months after the last Ebola case to measure the impact during and after the epidemic. By calculating the couple-years of protection from service statistics, we find that family planning distribution declined by 65 percent in Liberia and 23 percent in Sierra Leone at the peak of the epidemic. Two years after Ebola, Liberia's average monthly contraception distribution is 39 percent above precrisis levels, while distribution in Sierra Leone increased by 27 percent, findings echoed in data from the Demographic and Health Survey and Multiple Indicator Cluster Survey. Increased contraceptive use comes from implants in both countries, and injectables in Liberia. This study indicates that the family planning sector can recover, and continue to improve, following a significant disruption and is a lesson in resilience.

The nature of the open birth interval distribution.

Background: The open birth interval -- the time since the woman's latest birth -- is closely correlated to the usual fertility measures, but it adds important information from the age of the woman's youngest child, with its implications for her freedom from domestic roles.  Studies of the open interval by age and parity can elucidate the transitions in reproductive behavior that women experience over time. Methods:  249 surveys of married women in 75 countries in the DHS series provide information on the open  interval by age and parity, and by the  fertility measures of the total fertility rate (TFR), the general fertility rate (GFR), and children ever born (CEB), with time trends.  Stata 15 and the "R" software were used, and a two-parameter equation was employed to model the distribution. Results:  The distribution of women by the open interval follows a downward curve from birth to 20 years; it varies across countries and over time only by its starting level and the steepness of the curve. Declines in the shortest intervals soon after birth reflect recent fertility declines. Variations are large by both age and parity, but in quite different patterns. Past modeling analyses demonstrate the effects of female and spouse mortality, declining fecundability, contraceptive use, and reduced sexual exposure. Both period and cohort effects can impact the curve. The open interval distribution is modelled in an equation with two parameters and calculated for the latest surveys in the 75 countries. Conclusions: The time since a woman's birth is easily captured with a single question in successive surveys. Changes in the open interval distribution serve as sensitive indicators of recent fertility changes, and the dynamics of reproductive behavior across women's life stages are captured in new ways, as gauged by age and parity trends in the distributions.

Shifting dynamics: Changes in the relationship between total fertility rate and contraceptive prevalence rate in Jordan between 2012 and 2017.

Background: Between the two most recent Population and Family Health Surveys, Jordan saw a dramatic decline in the Total Fertility Rate (TFR) from 3.5 to 2.7 in 5.5 years.  Over the same period, modern contraceptive use also declined, from 61.2% to 51.8% among married women.  This decrease in both TFR and the contraceptive prevalence rate (CPR) diverges from the typical relationship seen between these two factors whereby historically as CPR increases, TFR decreases.  This paper explores this unique pattern using multiple methodologies.  Methods: First, we validate the survey data using nationally collected data on fertility and contraceptive distribution.  Second, we look to changes that have historically influenced changes in CPR and TFR, including changes in ideal family size and wanted fertility rates. Third, we explore proximate determinants and other influences on fertility and changes in contraception, examining the changes in the method mix and unmet need; marriage patterns, including the demographics of the married population, spousal separation, and time since last sex; postpartum insusceptibility; infecundity, both primary and secondary; and abortion, to see if any have shifted significantly enough to allow for fertility to decline with less contraceptive use. Results: We find that the decline in fertility in Jordan was driven by a reduction in mistimed or unwanted pregnancies and there was a significant increase in the share of reproductive aged women who are infecund. We also concluded that the changes in fertility and contraceptive use are driven by changes in Jordanian nationals, not by the growing Syrian refugee population. Conclusions: Jordan is not the only country to be experiencing a shift in the typical relationship between CPR and TFR.  Results can inform both future approaches for family planning programs and our expectations regarding what kind of change our family planning investments might buy.

Men's Attitudes Towards Contraception in Sub-Saharan Africa.

This paper examines male attitudes towards family planning in Sub-Saharan Africa. Studying attitudes is ideal as they can be calculated for all men, at any point in their lives, regardless of marital status, sexual activity, or fertility desires. We find that positive attitudes towards family planning have increased across Sub-Saharan Africa in the last two decades. We analyze both the association of positive attitudes with a variety of demographic characteristics (age, marital status, education, and religion) and the relationships with multiple forms of discussion about family planning (radio, television, friends, and partners). We find higher approval at older ages and higher levels of education, and lower levels of approval among Muslims compared to Christians. Interactions between characteristics and discussion of family planning. demonstrate that hearing or talking about contraception has different associations for different groups. This paper offers a new way to explore fertility and reproductive health in Sub-Saharan Africa.

Levels and correlates of non-adherence to WHO recommended inter-birth intervals in Rufiji, Tanzania.

BACKGROUND: Poorly spaced pregnancies have been documented worldwide to result in adverse maternal and child health outcomes. The World Health Organization (WHO) recommends a minimum inter-birth interval of 33 months between two consecutive live births in order to reduce the risk of adverse maternal and child health outcomes. However, birth spacing practices in many developing countries, including Tanzania, remain scantly addressed. METHODS: Longitudinal data collected in the Rufiji Health and Demographic Surveillance System (HDSS) from January 1999 to December 2010 were analyzed to investigate birth spacing practices among women of childbearing age. The outcome variable, non-adherence to the minimum inter-birth interval, constituted all inter-birth intervals <33 months long. Inter-birth intervals ≥33 months long were considered to be adherent to the recommendation. Chi-Square was used as a test of association between non-adherence and each of the explanatory variables. Factors affecting non-adherence were identified using a multilevel logistic model. Data analysis was conducted using STATA (11) statistical software. RESULTS: A total of 15,373 inter-birth intervals were recorded from 8,980 women aged 15-49 years in Rufiji district over the follow-up period of 11 years. The median inter-birth interval was 33.4 months. Of the 15,373 inter-birth intervals, 48.4% were below the WHO recommended minimum length of 33 months between two live births. Non-adherence was associated with younger maternal age, low maternal education, multiple births from the preceding pregnancy, non-health facility delivery of the preceding birth, being an in-migrant resident, multi-parity and being married. CONCLUSION: Generally, one in every two inter-birth intervals among 15-49 year-old women in Rufiji district is poorly spaced, with significant variations by socio-demographic and behavioral characteristics of mothers and newborns. Maternal, newborn and child health services should be improved with a special emphasis on community- and health facility-based optimum birth spacing education in order to enhance health outcomes of mothers and their babies, especially in rural settings.