Potential Cost-Effectiveness of Universal Access to Modern Contraceptives in Uganda

<div><h3>Background</h3><p>Over two thirds of women who need contraception in Uganda lack access to modern effective methods. This study was conducted to estimate the potential cost-effectiveness of achieving universal access to modern contraceptives in Uganda by implementing a hypothetical new contraceptive program (NCP) from both societal and governmental (Ministry of Health (MoH)) perspectives.</p> <h3>Methodology/Principal Findings</h3><p>A Markov model was developed to compare the NCP to the status quo or current contraceptive program (CCP). The model followed a hypothetical cohort of 15-year old girls over a lifetime horizon. Data were obtained from the Uganda National Demographic and Health Survey and from published and unpublished sources. Costs, life expectancy, disability-adjusted life expectancy, pregnancies, fertility and incremental cost-effectiveness measured as cost per life-year (LY) gained, cost per disability-adjusted life-year (DALY) averted, cost per pregnancy averted and cost per unit of fertility reduction were calculated. Univariate and probabilistic sensitivity analyses were performed to examine the robustness of results. Mean discounted life expectancy and disability-adjusted life expectancy (DALE) were higher under the NCP vs. CCP (28.74 vs. 28.65 years and 27.38 vs. 27.01 respectively). Mean pregnancies and live births per woman were lower under the NCP (9.51 vs. 7.90 and 6.92 vs. 5.79 respectively). Mean lifetime societal costs per woman were lower for the NCP from the societal perspective ($1,949 vs.$1,987) and the MoH perspective ($636 vs.$685). In the incremental analysis, the NCP dominated the CCP, i.e. it was both less costly and more effective. The results were robust to univariate and probabilistic sensitivity analysis.</p> <h3>Conclusion/Significance</h3><p>Universal access to modern contraceptives in Uganda appears to be highly cost-effective. Increasing contraceptive coverage should be considered among Uganda's public health priorities.</p> </div

Intentions to use contraceptives in Pakistan: implications for behavior change campaigns

<p>Abstract</p> <p>Background</p> <p>Since 1990-91, traditional method use has increased at a faster rate in Pakistan than modern method use. The importance of hormonal methods or the IUD has diminished and that of traditional methods has increased in the method mix. There is a need to identify factors motivating and deterring the adoption of specific family planning methods among married men and women in Pakistan.</p> <p>Methods</p> <p>In addition to social and demographic characteristics of respondents, a representative household survey collected information on psychological correlates of family planning behavior from 1,788 non-pregnant wives and 1,805 husbands with not-pregnant wives. Males and females were from separate households. Principal components analysis was conducted to identify the underlying constructs that were important for each gender. Multinomial logistic regression analysis was conducted to determine the correlates of male and female intentions to use contraceptive methods.</p> <p>Results</p> <p>Amongst women, the perception that her in-laws support family planning use was the strongest determinant of her intentions to use contraceptive methods. A woman's belief in the importance of spacing children and her perception that a choice of methods and facilities with competent staff were available were also powerful drivers of her intentions to use contraceptive methods. The strongest obstacle to a woman's forming an intention to use contraceptive methods was her belief that family planning decisions were made by the husband and fertility was determined by God's will. Fears that family planning would harm a woman's womb lowered a woman's intentions to use methods requiring procedures, such as the IUD and female sterilization.</p> <p>The perception that a responsible, caring, husband uses family planning to improve the standard of living of his family and to protect his wife's health was the most important determinant of a man's intention to use condoms. A husband's lack of self-efficacy in being able to discuss family planning with his wife was the strongest driver of the intention to use withdrawal. A man's fear that contraceptives would make a woman sterile and harm her womb lowered his intention to use modern contraceptive methods.</p> <p>Conclusions</p> <p>These findings highlight the importance of having secondary target audiences such as mothers-in-law and husbands in family planning behavior change campaigns implemented in Pakistan. Campaigns that stress the importance of child spacing are likely to have an impact. Client perceptions of the quality of care are important determinants of intentions to use contraceptive methods in Pakistan. Client concerns that the IUD and sterilization procedures might harm a woman's womb and cause sterility should be addressed. The findings suggest that there is a need to assess the actual quality of service delivery in Pakistan.</p

Clinical training alone is not sufficient for reducing barriers to IUD provision among private providers in Pakistan

<p>Abstract</p> <p>Background</p> <p>IUD uptake remains low in Pakistan, in spite of three major efforts to introduce the IUD since the 1960s, the most recent of these being through the private sector. This study examines barriers to IUD recommendation and provision among private providers in Pakistan.</p> <p>Methods</p> <p>A facility-based survey was conducted among randomly selected private providers who were members of the Greenstar network and among similar providers located within 2 Kilometers. In total, 566 providers were interviewed in 54 districts of Pakistan.</p> <p>Logistic regression analysis was conducted to determine whether correct knowledge regarding the IUD, self-confidence in being able to insert the IUD, attitudes towards suitability of candidates for the IUD and medical safety concerns were influenced by provider type (physician vs. Lady Health Visitor), whether the provider had received clinical training in IUD insertion in the last three years, membership of the Greenstar network and experience in IUD insertion. OLS regression was used to identify predictors of provider productivity (measured by IUD insertions conducted in the month before the survey).</p> <p>Results</p> <p>Private providers consider women with children and in their peak reproductive years to be ideal candidates for the IUD. Women below age 19, above age 40 and nulliparous women are not considered suitable IUD candidates. Provider concerns about medical safety, side-effects and client satisfaction associated with the IUD are substantial. Providers' experience in terms of the number of IUDs inserted in their careers, appears to improve knowledge, self-confidence in the ability provide the IUD and to lower age-related attitudinal barriers towards IUD recommendation. Physicians have greater medical safety concerns about the IUD than Lady Health Visitors. Clinical training does not have a consistent positive effect on lowering barriers to IUD recommendation. Membership of the Greenstar network also has little effect on lowering these barriers. Providers' barriers to IUD recommendation significantly lower their monthly IUD insertions.</p> <p>Conclusions</p> <p>Technical training interventions do not reduce providers' attitudinal barriers towards IUD provision. Formative research is needed to better understand reasons for the high levels of provider barriers to IUD provision. "Non-training" interventions should be designed to lower these barriers.</p

Why Men Matter: Mating Patterns Drive Evolution of Human Lifespan

Evolutionary theory predicts that senescence, a decline in survival rates with age, is the consequence of stronger selection on alleles that affect fertility or mortality earlier rather than later in life. Hamilton quantified this argument by showing that a rare mutation reducing survival is opposed by a selective force that declines with age over reproductive life. He used a female-only demographic model, predicting that female menopause at age ca. 50 yrs should be followed by a sharp increase in mortality, a “wall of death.” Human lives obviously do not display such a wall. Explanations of the evolution of lifespan beyond the age of female menopause have proven difficult to describe as explicit genetic models. Here we argue that the inclusion of males and mating patterns extends Hamilton's theory and predicts the pattern of human senescence. We analyze a general two-sex model to show that selection favors survival for as long as men reproduce. Male fertility can only result from matings with fertile females, and we present a range of data showing that males much older than 50 yrs have substantial realized fertility through matings with younger females, a pattern that was likely typical among early humans. Thus old-age male fertility provides a selective force against autosomal deleterious mutations at ages far past female menopause with no sharp upper age limit, eliminating the wall of death. Our findings illustrate the evolutionary importance of males and mating preferences, and show that one-sex demographic models are insufficient to describe the forces that shape human senescence

Risk factors and a predictive model for under-five mortality in Nigeria: evidence from Nigeria demographic and health survey

<p>Abstract</p> <p>Background</p> <p>Under-5 mortality is a major public health challenge in developing countries. It is essential to identify determinants of under-five mortality (U5M) childhood mortality because these will assist in formulating appropriate health programmes and policies in order to meet the United Nations MDG goal. The objective of this study was to develop a predictive model and identify maternal, child, family and other risk factors associated U5M in Nigeria.</p> <p>Methods</p> <p>Population-based cross-sectional study which explored 2008 demographic and health survey of Nigeria (NDHS) with multivariable logistic regression. Likelihood Ratio Test, Hosmer-Lemeshow Goodness-of-Fit and Variance Inflation Factor were used to check the fit of the model and the predictive power of the model was assessed with Receiver Operating Curve (ROC curve).</p> <p>Results</p> <p>This study yielded an excellent predictive model which revealed that the likelihood of U5M among the children of mothers that had their first marriage at age 20-24 years and ≥ 25 years declined by 20% and 30% respectively compared to children of those that married before the age of 15 years. Also, the following factors reduced odds of U5M: health seeking behaviour, breastfeeding children for > 18 months, use of contraception, small family size, having one wife, low birth order, normal birth weight, child spacing, living in urban areas, and good sanitation.</p> <p>Conclusions</p> <p>This study has revealed that maternal, child, family and other factors were important risk factors of U5M in Nigeria. This study has identified important risk factors that will assist in formulating policies that will improve child survival.</p

Fertility desires, family planning use and pregnancy experience: longitudinal examination of urban areas in three African countries

Background Many women have inconsistent fertility desires and contraceptive use behaviors. This increases their risk of unintended pregnancies. Inconsistencies may reflect barriers to family planning (FP) use but may also reflect ambivalence toward future childbearing. Using urban data from Kenya, Nigeria, and Senegal, this study examines the role of fertility desires and FP use behaviors on pregnancy experience over a 2-year follow-up period. Methods Data come from baseline and 2-year follow-up among urban women interviewed in Kenya, Nigeria, and Senegal. At baseline (2010/2011), women were asked about their future fertility desires (want child soon, want to delay >2 years, does not want) and current FP use. At midterm (2012/2013), women were asked if they were currently pregnant or had a birth in the 2-year period. We examine the association between baseline fertility desires and FP use with pregnancy experience and desirability of an experienced pregnancy. Results In the 2-year follow-up period, 27–39 % of women in union experienced a pregnancy or birth. In Kenya and Nigeria, 30–35 % of women using a modern FP method experienced a pregnancy/birth; the percentage with a pregnancy/birth was slightly higher among women not using at baseline (41 % in both countries). In Senegal, the distinction between pregnancy experience between users and non-users was greater (16 % vs. 31 %, respectively). In all countries, pregnancy was less common among users of long-acting and permanent methods; only a small percentage of women use these methods. Women not wanting any(more) children were the least likely to experience a pregnancy in the 2-year follow-up period. No differences were observed between those who wanted to delay and those who wanted soon. Multivariate findings demonstrate distinctions in pregnancy experience by fertility desires among modern FP users. Non-users have similar pregnancy experience by fertility desires. Conclusions Fertility desires are not stable; providers need to consider the fluidity of fertility desires in counseling clients. Programs focusing on new FP users may miss women who are the most motivated to avoid a pregnancy and need to switch to a more effective method; this will result in less unintended pregnancies overall

Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh

<p>Abstract</p> <p>Background</p> <p>Lack of data is a critical barrier to addressing the problem of stillbirth in countries with the highest stillbirth burden. Our study objective was to estimate the levels, types, and causes of stillbirth in rural Sylhet district of Bangladesh.</p> <p>Methods</p> <p>A complete pregnancy history was taken from all women (n = 39 998) who had pregnancy outcomes during 2003-2005 in the study area. Verbal autopsy data were obtained for all identified stillbirths during the period. We used pre-defined case definitions and computer programs to assign causes of stillbirth for selected causes containing specific signs and symptoms. Both non-hierarchical and hierarchical approaches were used to assign causes of stillbirths.</p> <p>Results</p> <p>A total of 1748 stillbirths were recorded during 2003-2005 from 48,192 births (stillbirth rate: 36.3 per 1000 total births). About 60% and 40% of stillbirths were categorized as antepartum and intrapartum, respectively. Maternal conditions, including infections, hypertensive disorders, and anemia, contributed to about 29% of total antepartum stillbirths. About 50% of intrapartum stillbirths were attributed to obstetric complications. Maternal infections and hypertensive disorders contributed to another 11% of stillbirths. A cause could not be assigned in nearly half (49%) of stillbirths.</p> <p>Conclusion</p> <p>The stillbirth rate is high in rural Bangladesh. Based on algorithmic approaches using verbal autopsy data, a substantial portion of stillbirths is attributable to maternal conditions and obstetric complications. Programs need to deliver community-level interventions to prevent and manage maternal complications, and to develop strategies to improve access to emergency obstetric care. Improvements in care to avert stillbirth can be accomplished in the context of existing maternal and child health programs. Methodological improvements in the measurement of stillbirths, especially causes of stillbirths, are also needed to better define the burden of stillbirths in low-resource settings.</p