Measurement of unmet need for contraception: a counterfactual approach

Unmet need plays a critical role in reproductive health research, evaluation, and advocacy. Although conceptually straightforward, its estimation suffers from a number of methodological limitations, most notably its reliance on biased measures of women's stated fertility preferences. We propose a counterfactual-based approach to measuring unmet need at the population level. Using data from 56 countries, we calculate unmet need in a population as the difference between: (1) the observed contraceptive prevalence in the population; and (2) the calculated contraceptive prevalence in a subsample of women who are identified to be from "ideal" family planning environments. Women from "ideal" environments are selected on characteristics that signal their contraceptive autonomy and decision-making over family planning. We find significant differences between our approach and existing methods to calculating unmet need, and we observe variation across countries when comparing indicators. We argue that our indicator of unmet need is preferable to existing population-level indicators due to its independence from biases that are generated from the use of reported preference measures, the simplicity with which it can be derived, and its relevance for cross-country comparisons as well as context-specific analyses.Published versio

Community-based financing of family planning in developing countries: A systematic review

In this systematic review, we gather evidence on community financing schemes and insurance programs for family planning in developing countries, and we assess the impact of these programs on primary outcomes related to contraceptive use. To identify and evaluate the research findings, we adopt a four‐stage review process that employs a weight‐of‐evidence and risk‐of‐bias analytic approach. Out of 19,138 references that were identified, only four studies were included in our final analysis, and only one study was determined to be of high quality. In the four studies, the evidence on the impact of community‐based financing on family planning and fertility outcomes is inconclusive. These limited and mixed findings suggest that either: 1) more high‐quality evidence on community‐based financing for family planning is needed before any conclusions can be made; or 2) community‐based financing for family planning may, in fact, have little or no effect on family planning outcomes.Funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored program executed by the World Health Organization, is gratefully acknowledged. The authors thank members of the WHO technical working group on financing family planning for their valuable comments. In addition, the authors thank Iqbal Shah for his support throughout the review process and for his technical guidance on this manuscript. (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); World Health Organization)Published versio

Reframing the measurement of women’s work in the sub-Saharan African context

This research note considers how we measure women’s work in the sub-Saharan African (SSA) context. Drawing on qualitative work conducted in Burundi, the note examines how existing measures of women’s work do not accurately capture the intensity and type of work women in SSA undertake. Transcripts from qualitative interviews suggest that women think of work to meet their roles and responsibilities within the household. The women in the interviews do not frame work as a career or a primary activity in a time-use allocation. As a result, researchers need to nest questions regarding women’s work within surveys that ask about roles and responsibilities within the household, and about how women meet these responsibilities with a financial component.Published versionAccepted manuscrip

Ethnolinguistic concordance and the receipt of postpartum IUD counseling services in Sri Lanka.

CONTEXT: Ethnic and linguistic concordance are important dimensions of the patient-physician relationship, and are linked to health care disparities. However, evidence on the associations between health behavior and outcomes and patient-provider concordance is limited, especially in low- and middle-income settings. METHODS: To examine how concordance between women and their primary health midwife is associated with women's receipt of postpartum IUD counseling, observational data from a cluster-randomized trial assessing an intervention to increase postpartum IUD counseling were used. Data on 4,497 women who delivered at six hospitals in Sri Lanka between September 2015 and March 2017 were merged with data on 245 primary health midwives, and indicators of linguistic concordance, ethnic concordance and their interaction were generated. Multivariate logistic regression analyses were used to assess the associations between concordance and women's receipt of counseling. RESULTS: Women from non-Sinhalese groups in Sri Lanka face disparities in the receipt of postpartum IUD counseling. Compared with the ethnolinguistic majority (Sinhalese women who speak only Sinhala), non-Sinhalese women have lower odds of having received postpartum IUD counseling, whether they speak both Sinhala and Tamil (odds ratio, 0.6) or only Tamil (0.5). Ethnic discordance- rather than linguistic discordance-is the primary driver of this disparity. CONCLUSIONS: The findings highlight the need for interventions that aim to bridge the sociocultural gaps between providers and patients. Matching women and their providers on ethnolinguistic background may help to reduce disparities in care.Accepted manuscrip

User-centered counseling and male involvement in contraceptive decision making: protocol for a randomized controlled trial

BACKGROUND: To achieve informed choice within the framework of reproductive autonomy, family planning programs have begun to adopt user-centered approaches to service provision, which highlight the individual client as the focal point of interaction and key decision maker. However, little is known about how user-centered approaches to family planning, particularly family planning counseling, shape contraceptive preferences and choices. OBJECTIVE: We conducted a multiarmed randomized controlled trial to identify the causal impact of user-centered approaches to family planning counseling on women's contraceptive decision making in urban Malawi. This study aims to determine how a tailored, preference-driven approach to family planning counseling and the involvement of male partners during the counseling process may contribute to shaping women's contraceptive preferences and choices. METHODS: Married women aged 18-35 years were recruited and randomly assigned to 1 of the 3 intervention arms or a control arm characterized by the following two interventions: an intervention arm in which women were encouraged to invite their husbands to family planning counseling (husband invitation arm) and an intervention arm in which women received targeted, tailored counseling on up to five contraceptive methods (as opposed to up to 13 contraceptive methods) that reflected women's stated preferences for contraceptive methods. Women were randomized into a control arm, T0 (no husband invitation, standard counseling); T1 (husband invitation, standard counseling); T2 (no husband invitation, targeted counseling); and T3 (husband invitation, targeted counseling). Following counseling, all women received a package of family planning services, which included free transportation to a local family planning clinic and financial reimbursement for family planning services. Follow-up surveys were conducted with women 1 month after counseling. RESULTS: A total of 785 women completed the baseline survey, and 782 eligible respondents were randomized to 1 of the 3 intervention groups or the control group (T1, n=223; T2, n=225; T3, n=228; T0, n=108). Furthermore, 98.1% (767/782) of women were contacted for follow-up. Among the 767 women who were contacted, 95.3% (731/767) completed the follow-up survey. The analysis of the primary outcomes is ongoing and is expected to be completed by the end of 2021. CONCLUSIONS: The results from this trial will fill knowledge gaps on the effectiveness of tailored family planning counseling and male involvement in family planning on women's stated and realized contraceptive preferences. More generally, the study will provide evidence on how user-centered counseling may affect women's willingness to use and continue contraception to realize their contraceptive preferences. TRIAL REGISTRATION: American Economics Association's Registry for Randomized Controlled Trials AEARCTR-0004194; https://www.socialscienceregistry.org/trials/4194/history/46808. Registry for International Development Impact Evaluations RIDIE-STUDY-ID-5ce4f42bbc2bf; https://ridie.3ieimpact.org/index.php?r=search/detailView&id=823. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24884.Published versio

Unwanted family planning: prevalence estimates for 56 countries

While there is a large literature on the prevalence of unmet need for family planning, there is no matching quantitative evidence on the prevalence of unwanted family planning; all contraceptive use is assumed to represent a "met need." This lack of evidence raises concerns that some observed contraceptive use may be undesired and coercive. We provide estimates of unwanted family planning using Demographic and Health Survey data collected from 1,546,987 women in 56 low- and middle-income countries between 2011 and 2019. We estimate the prevalence of unwanted family planning, defined as the proportion of women who report wanting a child in the next nine months but who are using contraception. We find that 12.2 percent of women have an unmet need for family planning, while 2.1 percent have unwanted family planning, with estimated prevalence rates ranging from 0.4 percent in Gambia to 7.1 percent in Jordan. About half of unwanted family planning use can be attributed to condoms, withdrawal, and abstinence. Estimating the prevalence of unwanted family planning is difficult given current data collection efforts, which are not designed for this purpose. We recommend that future surveys probe the reasons for the use of family planning.Published versio

Birth spacing and child health trajectories

Using longitudinal data on a cohort of over 4,000 children from four low‐ and middle‐income countries, we document the association between birth spacing and child growth trajectories. We find declines in child height at age 1 among children who are born within three years of an older sibling. However, we also observe catch‐up growth for closely spaced children as they age. We find no evidence that catch‐up growth is driven by remedial health investments after birth, suggesting substitutability in underlying biological processes. We also find that very widely spaced children (preceding birth interval of more than seven years) are similar in height at age 1 as children who are spaced three to seven years apart, but outgrow their more closely spaced counterparts as they age. However, further sibling comparisons suggest that the growth premium that is observed for very widely spaced children may be driven by unobserved confounding factors.Published versio

Long run height and education implications of early life growth faltering : a synthetic panel analysis of 425 birth cohorts in 21 low- and middle-income countries

We estimated the associations between exposure to early life growth faltering at the population level and adult height and education outcomes in a sample of 21 low- and middle-income countries.; We conducted a synthetic panel analysis of 425 birth cohorts across 126 regions in 21 LMICs surveyed in the Demographic and Health Surveys (DHS) both as children and as adults. Data from historic (1987-1993) DHS survey rounds were used to compute average height-for-age z-scores at the province-birth-year level. Cohort measures of early life growth were then linked to adult height and educational attainment measures collected on individuals from the same cohorts in the 2006-2014 DHS survey rounds. The primary exposure of interest was population-level early life growth (region-birth year average HAZ) and growth faltering (region-birth year stunting prevalence). Multivariable linear regression models were used to estimate the associations between adult outcomes and population-level measures of early life linear growth.; The average cohort height-for-age z-score (HAZ) in childhood was - 1.53 [range: - 2.73, - 0.348]. In fully adjusted models, each unit increase in cohort childhood HAZ was associated with a 2.0 cm [95% CI: 1.09-2.9] increase in adult height, with larger associations for men than for women. Evidence for the association between early childhood height and adult educational attainment was found to be inconclusive (0.269, 95% CI: [- 0.68-1.22]).; While early childhood linear growth at the cohort level appears to be highly predictive of adult height, the empirical association between early life growth and adult educational attainment seems weak and heterogeneous across countries.; This study was registered on May 10, 2017 at the ISRCTN Registry ( http://www.isrctn.com ), registration number ISRCTN82438662

Adding measurement error to location data to protect subject confidentiality while allowing for consistent estimation of exposure effects

In public use data sets, it is desirable not to report a respondent's location precisely to protect subject confidentiality. However, the direct use of perturbed location data to construct explanatory exposure variables for regression models will generally make naive estimates of all parameters biased and inconsistent. We propose an approach where a perturbation vector, consisting of a random distance at a random angle, is added to a respondent's reported geographic co‐ordinates. We show that, as long as the distribution of the perturbation is public and there is an underlying prior population density map, external researchers can construct unbiased and consistent estimates of location‐dependent exposure effects by using numerical integration techniques over all possible actual locations, although coefficient confidence intervals are wider than if the true location data were known. We examine our method by using a Monte Carlo simulation exercise and apply it to a real world example using data on perceived and actual distance to a health facility in Tanzania.Published versio

The effect of a postpartum IUD intervention on counseling and choice: Evidence from a cluster-randomized stepped-wedge trial in Sri Lanka

BACKGROUND: The International Federation of Gynaecology and Obstetrics (FIGO), in collaboration with the Sri Lankan College of Obstetrics and Gynaecologists (SLCOG), launched an initiative in 2014 to institutionalize immediate postpartum IUD (PPIUD) services as a routine part of antenatal counseling and delivery room services in Sri Lanka. In this study, we evaluate the effect of the FIGO-SLCOG PPIUD intervention in six hospitals by means of a cluster-randomized stepped-wedge trial. METHODS/DESIGN: Six hospitals were randomized into two groups of three using matched pairs. Following a 3-month baseline period, the intervention was administered to the first group, while the second group received the intervention after 9 months of baseline data collection. We collected data from 39,084 women who delivered in these hospitals between September 2015 and January 2017. We conduct an intent-to-treat (ITT) analysis to determine the impact of the intervention on PPIUD counseling and choice of PPIUD, as measured by consent to receive a PPIUD, as well as PPIUD uptake (insertion following delivery). We also investigate how factors related to counseling, such as counseling timing and quality, are linked to choice of PPIUD. RESULTS: We find that the intervention increased rates of counseling, from an average counseling rate of 12% in all hospitals prior to the intervention to an average rate of 51% in all hospitals after the rollout of the intervention (0.307; 95% CI 0.148-0.465). In contrast, we find the impact of the intervention on choice of PPIUD to be less robust and mixed, with 4.1% of women choosing PPIUD prior to the intervention compared to 9.8% of women choosing PPIUD after the rollout of the intervention (0.027; 95% CI 0.000-0.054). CONCLUSIONS: This study demonstrates that incorporating PPIUD services into postpartum care is feasible and potentially effective. Taking the evidence on both counseling and choice of PPIUD together, we find that the intervention had a generally positive impact on receipt of PPIUD counseling and, to a lesser degree, on choice of the PPIUD. Nevertheless, it is clear that the intervention's effectiveness can be improved to be able to meet the demand for postpartum family planning of women. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02718222 . Registered on 11 March 2016 (retrospectively registered).Published version and Accepted manuscript versions